September 2013

SAN FRANCISCO MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M E D I CA L S O C I E T Y

The Resident Experience Collected Tales, Obstacles, Passions, and Prospects

MICRA in Crisis The Sunshine Act What You Need to Know

SFMS Career Fair November 7, 2013

VOL. 86 NO. 7 September 2013

“ MIEC has never lost sight of its role as a physician advocate. MIEC provides comprehensive resources that range from handling difficult patients to helping me manage pain patients.

I feel confident that MIEC is dedicated to the protection of its policyholders.”

Dr. Mei-Ling Fong Member, San Francisco Medical Society Internal Medicine - Insured by MIEC

Join the Insurance Company that always puts policyholders first.

MIEC has never lost sight of its original mission, always putting policyholders (doctors like you) first. For over 35 years, MIEC has been steadfast in our protection of California physicians. With conscientious Underwriting, excellent Claims management and hands-on Loss Policyholder Dividend Ratio* Prevention services.

Added value: n No profit motive and low overhead For more information or to apply: n www.miec.com n n

Call 800.227.4527

Email questions to underwriting@miec.com

50%

47%

40% 29%

30% 20% 10% 0%

41%

39%

36% 30%

14% 2.2% 2007

6.4% 2008

5.2%

5.2% 2009

2010

6.9%

DISTRIBUTED

2011

Med Mal Industry (PIAA Composite)

8%

8%

2012

2013

MIEC

* (On premiums at $1/3 million limits. Future dividends cannot be guaranteed.)

MIEC 6250 Claremont Avenue, Oakland, California 94618 800-227-4527 • www.miec.com

SFmedSoc_ad_06.24.13

MIEC Owned by the policyholders we protect.

IN THIS ISSUE

SAN FRANCISCO MEDICINE

September 2013 Volume 86, Number 7

The Resident Experience FEATURE ARTICLES

MONTHLY COLUMNS

14 Learning to Make Mistakes: An Important Lesson in Residency

Renée M. Betancourt, MD

4

Membership Matters

5

Classified Ads

6

Ask the SFMS: MICRAEMERGENCY

8

The Sunshine Act: What You Need to Know

9

Executive Memo Mary Lou Licwinko, JD, MHSA

15 Home Sweet Home: Learning Home Care in Residency

Jeffrey K. Hom, MD, MPH 16 The Importance of Mentorship: A Personal Tale

LaKisha Garduño, MD

17 Learn One, Do One, Teach One: How to Be an Excellent

Resident Mentor to Medical Students

John Maa, MD 20 Access for the Insured: A Resident’s Barriers to

Obtaining Care

Daron Williams, MD

21 Resident Well-Being: Taking Care of Our Health Too

Hetty Eisenberg, MD; Eric Chang, MS3; David Elkin, MD 23 ACGME Duty Hour Reform: Unexpected Side Effects

Claudia Diaz Mooney, MD

24 Serving the Underserved: A Resident Finds Her Passion

Kyle Meehan, MD 25 Awakening in the ICU: Getting to Know Your Patients

Kim Nguyen, MD 27 Book Review: Stories from Female MDs

Erica Goode, MD

Resident Perspectives On pages 19 and 25 we’ve included short pieces by local residents about their experiences.

Editorial and Advertising Offices: 1003 A O’Reilly Ave. San Francisco, CA 94129 Phone: (415) 561-0850 e-mail: adenz@sfms.org Web: www.sfms.org Advertising information is available by request.

11 President’s Message

Shannon Udovic-Constant, MD

13 Editorial

Gordon Fung, MD, PhD, Philip R. Lee, MD,

and Steve Heilig, MPH 28 Medical Community News 30 In Memoriam

Nancy Thomson, MD

Welcome New Members The SFMS would like to welcome the following members:

Physicians

Anna Jadwiga Azziz, MD | Radiology Sarah J Janssen, MD | Occupational Medicine Michael Xiang Lee, MD | Hematology/Oncology Mark Alan Schrumpf, MD | Orthopaedic Surgery Kimberlee Ann Sorem, MD | Maternal and Fetal Medicine

Residents

Alice Ainsworth, MD Aamna Ali, MD Simon Ascher, MD Melissa Bent, MD Rachel Brim, MD Scott Caganap, MD Matt Careskey, MD Denise Chang, MD Monica Chen, MD Amy Chong, MD Michael B. Feldman, MD Kevin A. Gaudet, MD Courtney Green, MD Matthew Hamedani, MD Peter Hanna, MD Jordan Higgins, MD

Yen-michael Sheng Hsu, MD Wui Ip, MD Ali Khaki, MD Jeff Kim, MD Margaret Lowenstein, MD Heather McGee, MD Ian Metzler, MD Alexandra Ristow, MD Michael Dominic Scahill, MD, MBA Adrienne Shapiro, MD Nathan Stern, MD Gregory Summerville, MD Vivien K. Sun, MD Katherine Thomas, MD Nazneen Uddin, MD Emily West, MD Natalie Witek, MD

MEMBERSHIP MATTERS Activities and Actions of Interest to SFMS Members

Save the Date: SFMS Career Fair November 7, 2013!

Calling all residents, fellows, and employers! SFMS will be hosting our fourth annual Career Fair on November 7, 2013, at the UCSF Parnassus Campus. The event runs from 5:00 p.m. to 8:00 p.m. and is complimentary to residents and fellows from the four San Francisco-based residency programs. This is an excellent opportunity for physicians looking to practice in the Bay Area to network with representatives from a variety of practice types and settings and for employers to connect with physician job seekers.

As part of an effort to make participation accessible to all, we are offering a tiered pricing structure for employers; solo/ small group physician member practices can exhibit free-ofcharge. For event details or to inquire about exhibiting, contact the Membership Department at (415) 561-0850 or visit http://www.sfms.org/Membership/StudentResidents.aspx.

SFMS Physician Networking Mixer a Success

More than forty San Francisco physicians participated in SFMS’ Summer Networking Mixer at Ironside on August 15th. Attendees took advantage of the opportunity to meet SFMS leaders and connect with stakesholders from within our local medical community.

SFMS would like to thank Medical Insurance Exchange of California (MIEC) for their support of this event and the medical society.

With great attendance and positive feedback from all, SFMS plans to organize similar social networking events in the coming months. Please check the SFMS blog or follow SFMS on Twitter (@SFMedSociety) for event details.

Foster the Next Generation of Physicians; Volunteer Teaching Opportunities at UCSF

Make a lasting impression on future physicians by precepting a first- or second-year medical student in your practice setting. Please consider signing up for a volunteer teaching opportunity at UCSF through the Foundations of Patient Care program.

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San Francisco Medicine September 2013

All San Francisco physicians are eligible to participate. Time commitment ranges from a few hours to a few weeks. Please visit http://www.sfms.org/ForPhysicians/ProfessionalDevelopment. aspx for more information or contact Ivan Mendez at (415) 5143415 or mendezi@medsch.ucsf.edu.

SFDPH Health Alert: Surveillance for E. coli O157

Eight cases of presumptive Escherichia coli O157 were reported to the San Francisco Department of Public Health in late August. All of the reported cases have presented with bloody diarrhea, and one has progressed to hemolytic-uremic syndrome (HUS). To date the cases have not been linked to each other or to a common source.

San Francisco physicians are asked to 1) remain alert for adult or pediatric patients who have HUS or acute onset of bloody diarrhea; 2) obtain stool samples for culture from patients with bloody diarrhea and test those specimens for E. coli O157 as well as other suspect pathogens; 3) report cases of HUS or Shiga toxin-producing E. coli (STEC) including E. coli O157 immediately (within 1 hour) to SFDPH Communicable Disease Control Unit (415) 554-2830. For more information, please visit http://bit. ly/1707N0y.

September 16, 2013: Medicare EDI Transition from Palmetto GBA to Noridian

September 16, 2013, is the cutover date for transition of the Medicare Part B fee-for-service contractor from Palmetto GBA to Noridian. Although every effort has been made to minimize the burden to practices and to ensure that physicians continue to receive their Medicare payments in a timely fashion after the transition, physician practices will have to make some changes in their processes. Practices are encouraged to review the resources available regarding the transition on the SFMS website at http://bit.ly/15Sc6Oa.

DHCS to Implement 10% Medi-Cal Cuts in October

The Department of Health Care Services (DHCS) recently announced that it would begin to implement the 10% Medi-Cal physician payment rate reduction on October 1, 2013, for MediCal managed care and on January 9, 2014, for fee for service (FFS). DHCS also announced that it would be retroactively implementing the cuts for FFS providers to June 1, 2011, when the law authorizing the cuts went into effect. Specialty physician services in Medi-Cal managed care will not be subject to a reduction.

For more information about the rate reduction, please visit http://bit.ly/1fmElXw. www.sfms.org

Membership Desktop Reference

September 2013

The 2013-2014 SFMS Membership Directory and Physician Desk Reference has been mailed out to all active physician members.

The annual directory is one of the most valued benefits of membership, and is the only pictorial directory of physicians in San Francisco. This resource is complimentary to all SFMS physician members currently practicing medicine, and utilized throughout the year by physicians and their staff. For questions or information about the directory, please contact Jessica Kuo at (415) 561-0850 extension 268 or jkuo@sfms.org.

Volume 86, Number 7 Editor Gordon Fung, MD, PhD Managing Editor Amanda Denz, MA Copy Editor Mary VanClay

EDITORIAL BOARD Editor Gordon Fung, MD, PhD Obituarist Nancy Thomson, MD Stephen Askin, MD Erica Goode, MD, MPH Toni Brayer, MD Shieva Khayam-Bashi, MD Linda Hawes Clever, MD Arthur Lyons, MD John Maa, MD Chunbo Cai, MD

Free CME Seminar: Infectious Disease and Microbiome Update

SFMS members receive complimentary registration to the October 19 seminar on infectious disease offered by CPMC. Hear about updated treatment methods for HIV, MRSA, HPV, Hep C, TB, C. diff colitis, sinusitis, Lyme disease from leading regional specialists. For more information or to register, visit http://sfbaycme.com/.

SFMS Seminar—“MBA” for Physicians and Office Managers

October 25, 2013, 9:00 a.m. to 5:00 p.m. Join nationally acclaimed practice management consultant Debra Phairas for SFMS’ popular one-day seminar designed to provide critical business skills in the areas of strategic planning, finance, operations, marketing, and personnel management. This workshop teaches the core business elements of managing a practice that physicians don’t receive in medical school training. $225/each for SFMS/ CMA members and their staff; $325/each for non-members.

Lunch is included. Questions or to register, please contact Posi Lyon, plyon@sfms.org or (415) 561-0850 extension 260.

Complimentary Webinars for SFMS Members

CMA offers a number of excellent webinars that are free to SFMS members. Members can register at www.cmanet.org/events.

September 25: Appropriate Prescribing and Dispensing: New Measures • 12:15 pm to 1:15 pm October 2: Successful Medi-Cal Provider Enrollment for Physician Providers • 12:15 pm to 1:45 pm October 9: Benefits of Financing Your Electronic Medical Records Project • 12:15 pm to 1:15 pm October 30: CMS Quality Reporting Programs: What Physicians need to Know and Do Now to Improve Care and Avoid Penalties • 12:15 pm to 1:45 pm

Classified Ads

Share space with Podiatrist. Across from Mt. Zion hospital. $1500/month, call 650-245-2368.

FOR SALE: SF Family and Urgent Care Practice Average revenue $407,000; very high profit margin. No third-party plans; all cash. Strong growth potential. The practice is approximately half urgent care and half primary care. Real estate also available. Practice Consultants, info@ PracticeConsultants.com or 800-576-6935. www.sfms.org

SFMS OFFICERS President Shannon Udovic-Constant, MD President-Elect Lawrence Cheung, MD Secretary Man-Kit Leung, MD Treasurer Roger S. Eng, MD Immediate Past President Peter J. Curran, MD SFMS STAFF Executive Director Mary Lou Licwinko, JD, MHSA Associate Executive Director for Public Health and Education Steve Heilig, MPH Associate Executive Director for Membership Development Jessica Kuo, MBA Director of Administration Posi Lyon

BOARD OF DIRECTORS Term: Jan 2013-Dec 2015 Charles E. Binkley, MD Gary L. Chan, MD Katherine E. Herz, MD David R. Pating, MD Cynthia A. Point, MD Lisa W. Tang, MD Joseph Woo, MD

Term: Jan 2011-Dec 2013 Jennifer H. Do, MD Benjamin C.K. Lau, MD Keith E. Loring, MD Ryan Padrez, MD Terri-Diann Pickering, MD Adam Schickedanz, MD Rachel H.C. Shu, MD

Term: Jan 2012-Dec 2014 Andrew F. Calman, MD John Maa, MD Edward T. Melkun, MD Justin V. Morgan, MD Kimberly L. Newell, MD Richard A. Podolin, MD Elizabeth K. Ziemann, MD

CMA Trustee: Shannon Udovic-Constant, MD AMA Delegate: H. Hugh Vincent, MD AMA Alternate: Robert J. Margolin, MD

September 2013 San Francisco Medicine

5

PAYOR REIMBURSEMENTS HEALTH CARE

SFMS

DISPUTES

PHYSICIAN

MICRAMERGENCY

California physicians and the health care safety net are under attack. Trial lawyers are waging an aggressive and very public campaign directly attacking doctors, hospitals, and community clinics in an attempt to increase the value of medical lawsuits and payouts by significantly altering California’s Medical Injury Compensation Reform Act of 1975 (MICRA).

What Is MICRA?

MICRA is a series of statutes crafted to ensure that injured patients are fairly compensated, medical liability rates are kept in check, and physicians and clinics can remain in practice treating patients. The law has been targeted by the trial lawyers because it restricts the amount of money they can collect in damage awards.

Why Is MICRA Important?

During the early and mid-1970s, out-of-control medical liability costs were forcing community clinics, health centers, doctors, and other health care providers out of practice. Many physicians—particularly those in rural areas or in high-risk specialties such as obstetrics and neurosurgery—were forced to close their doors, either unable to get medical liability insurance or unable to afford it. Denied access to affordable care, California patients suffered. Governor Jerry Brown called a special session of the California Legislature to solve this crisis.

MICRA is the centerpiece of affordable and accessible highquality medical care in California and is an enduring public policy success. It ensures that patients suffering malpractice shall receive full and unlimited compensation for actual damages and, at maximum, an additional quarter-million dollars for noneconomic damages and “pain and suffering.” It contains meaningful and reasonable tort reform to reduce litigation and moderate its costs.

How Does MICRA Affect Physicians?

MICRA is a critical component of California’s fragile safety net to ensure patient access to health care. It saves California’s health care system billions of dollars each year and increases patients’ access to health care by keeping doctors, nurses, and other health care providers in practice and hospitals and clinics open. Specifically, MICRA:

6

KEEPING

San Francisco Medicine September 2013

CME

REFORM

CODING

MEDICAL RECORDS

MICRA

PROFESSIONAL DEVELOPMENT

FINANCIAL MANAGEMENT

BILLING

& IMPLEMENTATION

ASK THE

CONTRACT NEGOTIATIONS

EHR SELECTION

PRACTICE MANAGEMENT

• Lowers medical malpractice insurance premiums. San Francisco physicians save, on average, $95,000 per year compared to states without MICRA. • Improves access to care. MICRA ensures fair compensation for patients while also helping stabilize medical liability costs so doctors, clinics, and other providers can remain in practice, treating patients.

• Prevents frivolous lawsuits. MICRA’s cap on speculative, noneconomic damages dissuades trial lawyers from filing meritless lawsuits and collecting more legal fees.

What Are the Terms of the Trial Lawyers’ Proposed Ballot Measure?

Trial lawyers and their allies have filed a proposed ballot measure that will make it easier and more lucrative to file meritless health care lawsuits and, in turn, increase health care costs and reduce access to care. The initiative would increase MICRA’s on limit on speculative, noneconomic damages from $250,000 to more than $1.1 million. A recent study by an independent, nonpartisan legislative analyst found that merely doubling MICRA’s noneconomic damages cap to $500,000 would increase health care costs in California by $9.5 billion annually. A fourfold increase in MICRA’s cap will raise health care costs even more.

What Can I Do to Preserve MICRA? • Lend your voice to the fight for effective medical liability reform by contacting your state and federal representatives and asking them to preserve and support MICRA-like reforms.

• Take every opportunity to spread the word through the media and your patients, friends, and professional colleagues.

• Make a contribution to CMA’s Political Education Fund (1201 J Street, Suite 275, Sacramento, CA 95814) to help us advocate for and defend medical liability reforms.

• If you are not yet a member, please consider joining SFMS/ CMA to ensure that the voice of California physicians is heard loud and clear in the Capitol and beyond.

• Follow SFMS on Twitter (@SFMedSociety) for the latest news and updates on MICRA. www.sfms.org

savings of $ over 95,000 The Medical Injury Compensation Reform Act (MICRA) is California’s hard-fought law to provide for injured patients and stable medical liability rates. But this year California’s trial lawyers have launched an attack to undermine MICRA and its protections, and we need your help. Membership has never been so valuable!

WAYS SFMS-CMA IS WORKING FOR YOU!

San Francisco Physicians Are Saving an Average of $95,088 This Year Are you a SFMS-CMA member?

2012 SAN FRANCISCO MICRA SAVINGS CHART General Surgery

Internal Medicine

OB/GYN

Average

(Non-invasive)

San Francisco

$26,612

$7,392

$36,964

$23,656

Miami & Dade Counties, FL

$190,088

$46,372

$201,808

$146,089

Nassau & Suffolk Counties, NY

$127,233

$34,032

$204,684

$121,983

Wayne County, MI

$121,321

$35,139

$108,020

$88,160

FL-NY-MI Average

$146,214

$38,514

$171,504

$118,744

MICRA Savings

$119,602

$31,122

$134,540

$95,088

San Francisco Medical Society 1003 A O’Reilly Avenue, San Francisco, CA 94129 Phone: (415)561-0850 • Fax: (415)561-0833 * Medical Liability Monitor - Annual Rate Survey Issue, Vol. 37, No. 10, October 2012. Annual rates with limits of $1 million/$3 million.

Tracking of Industry Gifts to Physicians Begins in August Don’t Miss Your Chance to Challenge False or Misleading Data Before It Goes Public!

Beginning August 1, 2013, manufacturers of drugs, medical devices, and biologics that participate in federal health care programs must begin tracking and reporting certain payments and items of value—including consulting fees, travel reimbursements, research grants and other gifts—given to physicians and teaching hospitals. The new law, known as the Physician Payment Sunshine Act, also requires manufacturers and group purchasing organizations (GPOs) to report certain ownership interests held by physicians and their close family members. The intention of the law is to increase transparency and reduce the potential for conflicts of interest that can influence research, education, and clinical decision making.

The reports will be submitted to the Centers for Medicare and Medicaid Services (CMS) on an annual basis. The majority of the information contained in the reports will be made available on a public, searchable website beginning in September 2014.

Physicians will, however, have the right to review their reports and to challenge any information that is false, inaccurate, or misleading. By statute, physicians are provided, at a minimum, fortyfive days to review the transparency reports and make corrections before they are made public. The Sunshine Act covers all physicians who have an active state license, even if they do not participate in federal health care programs, but excludes residents and medical students. Payments of less than $10 do not need to be reported unless the aggregate amount exceeds $100 annually. The $10 threshold will increase every year, based on the Consumer Price Index.

How to Challenge False, Inaccurate, or Misleading Reports

Physicians will have forty-five days after the annual reports are completed to challenge the data before it is made public. The reports will be available to physicians for their review via an online portal sometime after the close of the calendar year. The portal will also facilitate contact between a physician with a dispute and the manufacturer/GPO that submitted the disputed information. Manufacturers then have fifteen days to correct any misinformation. If a resolution is not reached within the allotted time period, the disputed information will be flagged, but the report will be posted on a public web page. Physicians will, however, have two full years to contest or seek corrections to data contained in the reports, even after it has been made public.

Physicians are encouraged to proactively check with any manufacturer from which they have received payments or any items of value to see what information that manufacturer is tracking and intends to report. If you hold any ownership interests, you should also check to ascertain what the manufacturer intends to report.

(Ownership or investment interests in publicly traded securities and mutual funds are excluded from reporting.)

Some information in this article was republished with permission from the American Medical Association. For more information, visit www.ama-assn.org/go/sunshine.

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San Francisco Medicine September 2013

What You Can Do Now to Prepare for the Sunshine Act • Update your disclosures regularly. Ensure that all financial disclosures and conflict of interest disclosures required by employers, advisory bodies, and entities funding research, for example, are current and updated regularly.

• If you have an NPI, update the information and ensure your specialty is correctly designated. This information will be used by industry reporters, among other unique identifiers, to ensure that they have accurately identified you.

• Inform your industry contacts that you want ongoing notice of what they report to the government.

• Physicians are encouraged to register for the CMS Open Payments listserv to receive periodic e-mail updates about the program. To register, visit http://go.cms.gov/openpayments.

Send questions about the program to openpayments@cms.hhs.gov.

For More Information • AMA Sunshine Act Resource Page, http://www.ama-assn. org/go/sunshine • CMA On-Call Document #1150, “Gifts and Free Services.”

On-call documents are free to members in CMA’s online health law library at www.cmanet.org/cma-on-call.

• CMS Sunshine Act FAQ: https://questions.cms.gov/faq. php?id=5005&rtopic=2017

Key Dates

August 1, 2013: Manufacturers begin collecting and tracking payment, transfer, and ownership information.

January 1, 2014: CMS is expected to launch the physician portal that allows physicians to sign up to receive notice when their individual consolidated report is available for review. This portal will also allow physicians to dispute the accuracy of a report.

March 31, 2014: Manufacturers/GPOs report ’13 data to CMS. June 2014: CMS is expected to provide physicians with access to their individualized consolidated reports for the prior calendar year. Physicians will be able to access the reports online and will be able to seek correction or modification by contacting the manufacturer/GPO via the Web portal.

September 30, 2014: CMS will release most of the data on a public website.

Exemptions

• Samples intended for patient use, including coupons and coupons to obtain samples • Certified and accredited continuing medical education activities funded by manufacturers • Educational materials ultimately intended to be used with patients (for example, wall models or anatomical models) • Buffet meals, snacks, soft drinks, or coffee generally available to all participants of large-scale conferences or similar largescale events • The loan of a medical device for a short-term trial period • Discounts (including rebates) • In-kind items used for the provision of charity care • A dividend or other profit distribution from a publicly traded security or mutual fund www.sfms.org

EXECUTIVE MEMO Mary Lou Licwinko, JD, MHSA

SFMS Targeted by Anti-MICRA Forces As has been widely publicized by the San Francisco Medical Society (SFMS) and the California Medical Association (CMA), trial lawyers have been gearing up to raise the cap for noneconomic damages on the Medical Injury Compensation Reform Act (MICRA).

We know that some of our members are too young to remember the MICRA battles in years past, so we have included a brief informational piece on MICRA on page 6. For all of us who remember the last battle, it is interesting to note the latest tactics.

Having been defeated in the legislature a number of times, the anti-MICRA forces are taking a new tack. They have filed to put the issue on the ballot for 2014 and have couched the attempts to raise the cap as a patient safety issue. Thus they have included provisions in the initiative that require random physician drug testing and mandatory drug testing in the case of an adverse event. While trying to cloak the real intent of the initiative in the patient-safety mantle, the trial lawyers have also requested more funding for the CURES program and changes to the oversight powers of the California Medical Board. It is clear that the real intent is to increase the “cap” fourfold, allowing lawyers to collect higher legal fees.

Interestingly, the lawyers have enlisted the California Nurses Association, among others, to assist in their efforts, while the pro-MICRA coalition includes not only physicians but the American Nurses Association, Planned Parenthood, public hospitals, rural health clinics, public health departments, labor unions, and many, many more. Clearly, all of these groups understand that increases in legal fees will only take money out of an overburdened health care system and send the cost of insurance for physicians, hospitals, clinics,

and other health care providers sky-high. Under MICRA, the average size of medical liability awards has increased faster than inflation, with the bulk of the awards going to patients, not lawyers.

Over the last several months, SFMS has been talking about MICRA through our website, LinkedIn, Twitter, and Facebook updates. Meanwhile, anti-MICRA folks have dedicated numerous resources to monitoring and posting inflammatory information in response to pro-MICRA postings on social media platforms. Lately SFMS has been targeted with comments about greedy doctors and doctors who cannot be held accountable for killing their patients, appearing in response to SFMS tweets about preserving MICRA and ensuring accessible health care for all. But of course, we will not be deterred by such tactics. We will continue to work with the CMA to maintain the current MICRA cap. However, countering a ballot measure is an expensive business, so we encourage those of you who have not already done so to make a contribution to support MICRA by mailing a check, payable to Political Education Fund, to California Medical Association, 1201 J Street, Suite 275, Sacramento, CA 95814.

Follow SFMS on Twitter (@ SFMedSociety) for the latest news and updates on MICRA.

MICRA Preserves Patients’ Access to Fair Compensation When They Have Justifiable Claims, Including: • Unlimited economic damages for all past and future medical costs • Unlimited economic damages for lost wages, lifetime earning potential and for any other conceivable economic losses • Unlimited punitive damages, which seek to punish a defendant.

• Additional up to $250,000 available for non-economic damages, sometimes called pain and suffering awards

www.sfms.org

September 2013 San Francisco Medicine

9

s L S ice t c A ER isco Pra C l LO LOYn FraMnecdica a d P g S an n i s EMFeatusr pital o

y Ba

H ea

Ar

UCSF Millberry Conference Center 500 Parnassus Ave, San Francisco

Refreshments and hors d’oeuvres provided by the SFMS For detailed event information, including a list of confirmed exhibitors, please visit http://www.sfms.org/Membership/StudentResidents.aspx 11

San Francisco Medicine September 2013

www.sfms.org

EVENT OPEN TO ALL UCSF, CPMC, ST. MARY’S, AND KAISER PERMANENTE SF RESIDENTS AND FELLOWS

PRESIDENT’S MESSAGE Shannon Udovic-Constant, MD

Mentoring Could Help You Live Longer I ask the teenagers in my practice what they are happiest doing. I tell them that the trick to being a happy adult is to figure out how to get paid to do what makes you happy.

That is how I often feel about my work. I feel very lucky to be able to get paid to be a pediatrician.

It brings me great joy. Most of the time. There are frustrating days when I daydream about winning the lottery and moving to Hawaii to spend my days reading and taking long walks on the beach, but the majority of the time I love my job.

Dr. Albert Schweitzer once said, “The only ones among you who will be really happy are those who will have sought and found how to serve.”

This is one of the reasons that I volunteer as faculty to be a preceptor for UCSF medical students in their second year as they learn about specifics of the pediatric patient exam and also for third-year pediatric clerkships. I want to share my joy in serving in this profession with the next generation. I also have had some college students shadow my practice to see a day in the life of a physician. One of the students that shadowed me recently sent me a copy of his personal statement for medical school applications. He cites his shadowing of my practice (and my husband’s general surgery practice) as influential experiences in his decision to apply to medical school.

I hope that these hours spent will encourage those coming behind me to join this profession and also to choose primary care—of which the rewards are many but the hours can be long. It is partly for selfish reasons that I mentor, because I want smart, educated physicians to come behind me to continue to advocate for our profession.

While I am teaching and mentoring, I continue to read about physicians who wouldn’t choose medicine as a career again or who wouldn’t want their children to go into medicine. I would choose it again and would be extremely happy if one or both of my children chose medicine. I feel so honored that patients trust me with their health and that at the end of the day I helped someone feel better. We all can guess as to the reasons that some say that they wouldn’t choose medicine again. There are increasing regulations, coding, and other administrative burdens that pull us further and further away from the actual care of our patients. With reimbursement cuts and the pressure on physicians to slow the cost curve of American health care, many practices are turning to squeezing more patients into an already busy day. As a result of seeing more patients, a very successful pediatrician colleague just decided to stop precepting third-year medical students because it adds time to her day to do this. She is not alone. The physician who heads the UCSF preceptor program recently www.sfms.org

came to the medical society asking for our help to get more preceptors to sign up because last year it was difficult to find enough physicians to participate.

The crazy thing is that during times of working harder and more stress, I would encourage physicians to voluntarily agree to work more. There is good science that shows that working harder, if that work is volunteering, will increase satisfaction. Research has found that volunteering increases all measures of happiness, including life satisfaction and one’s sense of control over life, and it also leads to better physical health. Some research has shown that people who do volunteer work are even likely to live longer by another four years.

It is thought that this occurs by decreasing stress hormones.

Studies have found that 61 percent of people who volunteer at least five times a year say volunteer work helps them feel less stressed (B. Nelson, 2006, The Daily Record).

Hopefully the above is convincing as to the benefits of serving as a preceptor, but despite the importance of helping guide the next generation of physicians, the reality is that it is getting harder and harder to be a physician. SFMS/CMA continues to advocate vigorously on behalf of San Francisco physicians to maintain our profession as one that we want our young people to join.

As I daydream of my retirement, I continue to think of myself beach walking and reading. The San Francisco Chronicle recently had an article discussing the need to carefully choose a mentor to guide you in how to have a fulfilling retirement. As my retirement is many years off, I will continue to serve as a mentor. As social activist and writer Dick Gregory stated, “One of the things I keep learning is that the secret of being happy is doing things for other people.”

If you would like to serve as a preceptor for UCSF medical students, please contact Ivan Mendez at mendezi@medsch.ucsf. edu or (415) 514-3415. Alternatively, additional information can be found at http://www.sfms.org/ForPhysicians/ ProfessionalDevelopment.aspx.

September 2013 San Francisco Medicine

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IS Protecting medical liability reform The American Medical Association is proud to be helping the California Medical Association protect California’s medical liability laws. A strong liability climate allows physicians to do what they do best—focus on positive outcomes for patients.

The AMA and the CMA support you in the state house, the courthouse and in your practice. Working together with the CMA, the AMA will continue to make a difference.

Be a part of it. ama-assn.org/go/memberadvocate Please activate your 2014 AMA membership.

Visit ama.assn.org/go/join or call (800) 262-3211.

© 2013 American Medical Association. All rights reserved.

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San Francisco Medicine September 2013

www.sfms.org

EDITORIAL Gordon Fung, MD, PhD, Philip R. Lee, MD, and Steve Heilig, MPH

It’s Not Too Late: A Dozen Topics Neglected in Medical Training Medical training is filled with important topics and as knowledge increases it is ever more difficult to “triage” what is most essential. Thus, it is problematic to suggest that even more be taught in those finite years of formal medical education. However, there is also much evidence that some important topics are too often neglected.

What follows is a somewhat subjective list—but one based upon research, reports, and experience.

1. ADDICTION: The AMA has called drug abuse our nation’s number one public health problem (although obesity may be overtaking that slot). The addicted are not just the stereotypical street junkie, but everyday patients misusing legal drugs such as alcohol, tobacco, and prescription medications. Co-diagnoses of depression and other psychiatric issues are also often neglected. Many MDs are not very knowledgeable about addiction and are uncomfortable addressing it.

2. NUTRITION AND COMPLEMENTARY THERAPIES: Many patients utilize nutritional supplements and other “al-

ternative” or “complementary” approaches most physicians know little about—and patients often suspect that. Physicians should become informed about and counsel their patients regarding nutrition 3. SEXUALITY: How comfortable is the average MD in talking about sexual practices and health? Homosexuality? Sexual dysfunction? Sexually-transmitted infections? Contraception? Taking the time to delve into the “uncomfortable” realms of sexuality can not only strengthen rapport but will allow an MD to address specific health needs that tend to go unrecognized.

4. PAIN: Pain, particularly chronic pain, is often under-treated in this country, particularly toward the end of life. On the reverse side of the equation is the epidemic of prescription drug abuse, which often requires a delicate balance of needs. Much improvement in measuring and treating pain has taken place in recent years; more physicians need to become current on such skills.

5. END-OF-LIFE CARE: Medicine is not only about “cure,” but also about caring for patients when that is no longer an option.

Palliative care is a growing discipline with great rewards. Physicians need to know how to help ease patients (and their loved ones) into a palliative mode, to use therapies and medications in optimal ways as death approaches, and to work with skilled hospice and other such professionals.

6. PHYSICAL FITNESS: We all know exercise is good.

Our bodies are built to be used vigorously. But too many people are sedentary, and how many MDs are able to effectively address and motivate patients towards fitness and weight loss?

7. MEDICAL ETHICS: Ethical questions are common in clinical practice. Hospitals are required to have an ethics committee to address ethical issues. But ethics education varies widely in quality and, as with other clinical skills, many MDs need training about current ethical standards and practice.

8. VIOLENCE: We unfortunately live in a violent world. Anyone who has spent much time in an emergency department knows www.sfms.org

that, but most violence is more concealed. “Domestic” violence is endemic in our society. It too often goes unrecognized, untreated, and unreported. Physicians need to learn optimal methods of recognizing and treating intimate/partner abuse.

9. ENVIRONMENTAL HEALTH: Our environment affects our health in many ways. Knowledge is rapidly growing about the impact of pollution, chemicals, and the “built environment” on our health, and an “environmental history” may become a part of good clinical assessment—particularly for children, who may be more severely impacted. Physicians have the unique opportunity to link personal and environmental status.

10. HEALTH POLICY: Clinicians may wish that their practices exist in social vacuums, but decisions made in legislative arenas impact clinical problems. Public health and prevention have long been neglected factors in medical education and practice. Yet physicians have high credibility among the public and legislators, and that prestige is heightened when a respected clinician speaks and acts on behalf of policy issues and public health. Get involved.

11. THE “BUSINESS” OF MEDICINE: Physicians are often not taught much about how to run a medical practice, or at least about the financial side of medicine. Depending on what type of practice environment a doctor works in, this is more or less important, but all should know about health insurance, managed care, and so on, including details of the “medical market” where one intends to practice.

12. YOUR OWN WELL-BEING: Physicians can be at elevated risk for depression, substance abuse, and even suicide. Frustration in meeting expectations—both external and internal—stress, and the challenge of leading a balanced life are common problems.

Combine that with a reluctance to show or share such problems, let alone seek assistance, leads many physicians to struggle with an unrewarding life and career. Physicians need to be aware of resources available to address their needs, able to define and maintain priorities, and recognize the numerous daily rewards that are unique to the medical profession—because there are indeed many!

Again, there are resources to help clinicians become adept in addressing these issues as they practice and continue to learn; we wish you a most rewarding career.

Note: This is a truncated reprint of this article. See the September 2010 issue of San Francisco Medicine, available at sfms.org, for the full length piece with more information and resources. Steve Heilig is assistant executive director for public health and education for the SFMS. Dr. Philip Lee is Chancellor Emeritus of UCSF, former United States Assistant Secretary of Health, and Professor Emeritus at both UCSF and Stanford. Gordon Fung is Professor of Medicine at UCSF and Editor of San Francisco Medicine.

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The Resident Experience

Learning to Make Mistakes An Important Lesson in Residency Renée M. Betancourt, MD I remember the day in medical school when I decided to practice medicine without making a single mistake. On the day devoted to learning about medical er-

rors, we broke into small groups to discuss the theme, proctored by physicians with decades of experience. Sitting around the conference room table, surrounded by medical journals and my peers, I pondered the phenomenon of making an error. Our facilitator, a pediatric otolaryngologist, recounted some of his previous errors and his feelings about those cases. A thought crept into my consciousness: If I worked hard enough, maybe I could avoid errors. Silently, I crafted a plan to double-check all medications and doses before prescribing, to develop a complete differential for each presenting complaint, and to learn all of medicine. Surely, if I could just carry these steps through, no patient would suffer because of care I gave, and certainly no one would ever die as a result of a mistake I made.

Even at the time, I knew this was not realistic. Some more rational and mature corner of my brain chided my inner eightyear-old for wanting to be perfect. Though now, I wonder how many of us are out there: We got all A’s in school, we did well on the wards, and we wanted to do just as well as physicians. So it should only follow that we would practice medicine without errors or adverse events. But this is where the plan falls short: Doing well in medicine requires that we learn how to make mistakes. And make them well.

Even if we wanted to avoid errors, we could not. Numerous studies have shown that adverse events occur regularly in the hospital, with an incidence ranging from 2.9 to 9 percent (Baker et al, Brennan et al, Schioler et al, Thomas et al). It seems as though the patients of interns and residents may be at even greater risk. A 2004 review of postoperative infections and blood clots showed that these events were more common in hospitals where interns and residents were practicing (Duggirala et al). Contemplating these data, I wonder about the physical price that patients pay so that I, and my fellow residents, may learn.

At this point in my training, errors are no longer an academic question. This past year, a patient died unexpectedly while under my care. In the immediate moments after her passing, I reassured my team that we provided the best care that we could, and that we were capable and compassionate in her last moments. However, I spent the next several nights compulsively reviewing every choice we made during her hospitalization—playing certain moments over and over in my head. During the day, I did whatever I could to hide just how awful I felt.

When a colleague helpfully suggested we initiate a morbidity and mortality conference to investigate our decisions, I felt that I was being attacked. A new sense of doubt crept into my day, 14 15

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even into the most simple of decisions.

I am not alone in my feelings about medical errors or adverse events. A 1991 survey of residents (Wu et al) showed that some of the most common responses to errors included feeling remorseful, angry at themselves, guilty, and inadequate. It also reported that 98 percent of residents made at least one constructive change to their practice of medicine as a result of their errors.

Time passed, and with the natural perspective that time graciously lends, I gained new insights. My initial feelings of guilt and shame, though understandable, shifted the focus of my attention from my patient to myself. To honor what my patient went through, I needed to dispassionately review her case from start to finish, as well as my role in it. Had I continued to indulge my intense emotions, I would have missed the opportunity to look evenly at the care our team provided. I would not have been able to use my experience with this patient to shape my care of future patients.

I became a different physician because of this patient. Looking back on myself as a medical student who was constructing a plan to avoid the messy business of errors all together, I want to advise her. You will make errors. You cannot stop that from happening with a plan to double-check everything, and there is no such thing as learning all of medicine. Every time you make a mistake or a patient has an adverse outcome, do an autopsy of the patient’s care. Did you make an error of omission or commission? Did you ask for help during the case? Did you talk to your patient and her family about the event?

Teaching hospitals may offer our patients more cuttingedge treatments and the care of a larger number of physicians.

These same teaching hospitals may also subject our patients to adverse events at the hands of learners. Honoring patients’ vulnerability requires that we experience our negative feelings following an adverse event, but that we forgo wallowing in guilt and inadequacy. With compassion for ourselves, we need to metabolize those emotions to move swiftly to a place of humility and learning.

An older physician told me, “Every doctor has a cemetery that she keeps in her head.” I think that is true, and I’ve learned not to bury these experiences. Instead, I hold them in memoriam.

Renée M. Betancourt, MD, received her medical degree at the University of Pennsylvania. She is a third-year resident in the Department of Family and Community Medicine at University of California San Francisco/San Francisco General Hospital. She is from Philadelphia, Pennsylvania. References available online at www.sfms.org. www.sfms.org

The Resident Experience

Home sweet home Learning Home Care in Residency Jeffrey K. Hom, MD, MPH “You must be hungry. Let me serve you some of the soup we just made.” Without waiting for a reply, my

patient, an affable ninety-year old woman, shuffled ably from the dining room table to the adjacent kitchen, ladled out a rich broth, and returned with bowls, spoons, and a grin on her face.

In her home, she seemed like a different person. Away from the glaring lights and flat colors of the clinic walls, she was a brighter, more animated woman, eager to focus on the stories of her life rather than her chronic medical conditions and the home safety evaluation I had come to follow up on.

She was suddenly “younger than stated age” as the stories of her life unfolded before us. ***** Our residency’s Housecalls rotation offers us the chance to visit our patients in their homes, a valuable reminder that the majority of our patients’lives occur away from the hospital and clinic. They are not just “the seventy-five-year-old man with poorly controlled diabetes” or “the fifty-eight-yearold woman with breast cancer.” While the one-liner is at times necessary, our using them too frequently reduces a complex individual with a lifetime of relationships, careers, ambitions, fears, and dreams to little more than a medical record number. To the patient these are the pertinent positives, important pieces of their life that provide the context for their medical problems.

Having relationships with others and being able to help them over the course of a lifetime are elements that drew many of us to primary care and to medicine more broadly.

Yet the social history, where we might learn how our patients came to us and how we can best care for them, is often the first thing to go as we prioritize being efficient interns and residents.

The Housecalls Program, started in 1999 as part of the UCSF Division of Geriatrics, seeks to counterbalance that tendency. It complements our rigorous inpatient training by providing us dedicated time to care for our most elderly and frail patients, the frequently homebound individuals for whom the twenty-minute clinic visit is most insufficient.

Our home visits are structured, purposeful appointments in which we visit our patients in their residences and learn to provide home care. Our black doctor’s bag in hand, we use these visits to advance our patients’ medical care. But they also help us identify physical and psychosocial needs that less commonly arise in clinic. Are night-lights needed? Do the rugs pose fall risks? Can they hear the phone or use it to make an emergent call? Are they lonely?

Free from the pressures of getting to my next patient in www.sfms.org

the waiting room, I am also able to focus my efforts on issues that I had deferred for too long. Advance care planning and POLST forms are important parts of treatment plans, particularly for this population, but too often do I claim in clinic that there is not enough time. In a safe space, and frequently accompanied by the family members with whom they live, my patients have been receptive to having this important discussion during home visits. With our ability to document these conversations right into our laptop EHR and upload photos of completed forms, our time is used well, the emphasis placed on our patients in that moment and what they are telling us.

Housecalls similarly enables us to see our patients following hospitalizations. Many times my patients have returned home. But sometimes they have not, discharged instead to skilled nursing or rehabilitation facilities. Regardless of the disposition, these transitions are often crucial times. A home visit allows me to see a patient’s potentially new baseline or share information with nurses who may be caring for them.

Perhaps most critical is the opportunity to do good medication reconciliation. We hear that transitions are risky times, yet it is when reviewing the list and seeing the duplicate statins, the aggressive insulin sliding scales, the multiple PPIs, and the high doses of pain medications that the vulnerability

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The Resident Experience

The Importance of Mentorship A Personal Tale LaKisha Garduño, MD

I walked into the room to find a tired African-American woman sitting in the chair watching her two daughters, both under four years old, playing on the swivel stool in the center of the room. The two girls

wore matching outfits and hair ties, very similar to how I would dress my own daughters. That morning, prior to their first appointment, I received a significant pile of medical records for the family with a note from their case manager clipped to the front.

As I waded through the stack of EMR notes from outside hospitals, I was overwhelmed by the family’s list of problems, yet impressed with their strong sense of resilience.

They had moved through three different county health systems in two years and now were living in San Francisco. As a mother of two young girls, both under three years old, I could completely understand the duality of intense exhaustion and immense pride in raising children. Within minutes of their visit, it 16 17

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was clear. She had previously seen a lot of doctors and had received many diagnoses, but what they truly needed was “care.” In the whirlwind of one visit with three patients, as a first-year resident, two things were established: I was their new family doctor, and I would be delivering their “care.”

Remarkably, one year and countless visits later, I became very familiar with the framework of their social history, and yet there never seemed to be enough time to explore the details. I was most curious about my patient’s upbringing and how she maneuvered through the tough circumstances that she had been dealt. I imagined that we had lived in similar communities, both growing up in the Bay Area, enjoying the same foods, and remembering where we were during the 1989 Loma Prieta earthquake.

But there were also stark differences in our paths that lead me to medicine and her to become my patient in a safety-net clinic.

The opportunity to explore my patient’s story came during a session that was structured as a part of our Behavioral Health curriculum. This visit wasn’t in our traditional exam room but rather a meeting room that resembled a living room. She came alone and, as she walked in, the tone of the room was instantly different. Immediately my patient noticed that I was not wearing my white coat, and she commented, “It’s so nice to see you without your white coat.” In medicine, the white coat is a distinction of our profession. I have come to realize that it can also serve as my cloak of protection, separating me from the emotions of my environment by establishing a physical space between me and my patients. It was evident that my patient had sensed the latter and now, with that barrier removed, our conversation proceeded in a new and different way.

As we sat side by side, our conversation had a natural ease.

She then paused and said, “It is nice to have a black doctor.” Prior to this point our shared ethnicity hadn’t been explicitly discussed. Naturally we related to each other through our common gender, ethnicity, and experience. I am always humbled when a patient shares their appreciation for my presence as an AfricanAmerican doctor. It signifies their gratitude for my hard work and acknowledges the skill I have gained. It is what motivates me to continue on this path, despite my many obstacles. A unique exchange occurred that day. From observations of ethnically concordant doctor-patient relationships, we have learned that interpersonal trust, a deeper familiarity of the patient’s life story, and a sense of affiliation are included in this exchange. Undoubtedly she had placed trust in our relationship.

Among our many similarities, we differed in regard to the presence of positive role models in our lives. As a child she was discouraged from seeking out her dreams and was told by members of her own community that success was unattainable. My

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The Resident Experience

Learn One, Do One, Teach One How to Be an Excellent Resident Mentor to Medical Students John Maa, MD A third-year medical student in Boston is assigned to the Emergency Department (ED) and a patient with thrombosed hemorrhoids. Instructed

by the ED resident to page the on-call surgery chief resident to request evacuation, the student notices the ED attending and residents are grinning. A female surgery resident answers the page. Seconds into the student’s history and physical, he is chastised as giving the most disorganized presentation the resident has ever heard, until she recognizes that he must be a new third-year medical student. She instructs the student to wait by the patient’s bedside, so they can examine the patient together and improve his H&P. But on arrival, she discovers something the student and ED resident had overlooked: that in addition to the thrombosed hemorrhoids are signs of infection and a perianal abscess. The surgery resident shares her displeasure before storming off to prepare the patient for surgery. As the student walks back to the workstation, he sees that the ED attending and residents are still grinning, and he wonders why. They tell the student that the surgery resident always behaves that way, which is why they made the student call the consult.

Fast-forward a month. It is now time to rotate onto the wards. The student is learning how to remove chest tubes.

One evening after ward rounds, the same chief resident is reviewing X-rays with an intern and the student. The chief first asks the intern, “Was this chest X-ray taken on water seal, or on suction?” The intern is baffled. The student replies correctly, and the chief, impressed, says, “Not bad for a little thirdyear med student.”

Fast-forward a year. The student decides to do a sub-internship in general surgery at the same hospital. Guess who is now the super chief in general surgery? The same resident— but as the student’s interest in general surgery is now clear, the former chief treats him with a higher level of respect as a fellow surgeon in training.

Fast-forward another year, when our student arrives on the West Coast to start his internship in general surgery. As he walks into the orientation, the first person he runs into is the same chief resident, who is now a new junior faculty member.

During residency, she convinces the student to undertake research in her lab.

Years later, the student becomes a junior faculty member who asks for his former chief resident’s advice with tough surgical cases. For nearly five years, they have offices next to each other, the marvelous outcome of a connection in the ED more than twenty-one years previously.

From an educational perspective, there are aspects to this story that are not ideal—delegating the new third-year www.sfms.org

student to call a consult, intimidating consultants, and not offering structured feedback. But other things went well, particularly the evolution of the student-teacher mentoring relationship over the years. The comments below, from Dr. Haile Debas, who has served as department chair, School of Medicine dean, and UCSF chancellor, are relevant to residents who seek to improve their teaching quality.

The mentor should be very honest about what he/she knows. If he/she does not know the answer to a question, or is uncertain . . . the mentor should not only say so but should also engage the student in discussing how to find the answer. I also think the mentor should make every effort possible to know the students personally so that they would gain his/her confidence.

Such a relationship provides opportunities in which the mentee would bring up issues that may otherwise not arise in the course of structured mentorship interactions. Finally, the students should be accorded respect and made to feel important to the process of mentorship. I have found my career in academic medicine most fulfilling because of my interaction with my students and residents . . . they have been my best teachers.

Every year, the graduating UCSF medical school class presents the Teaching Excellence Award for Cherished Housestaff to residents who have been outstanding teachers, mentors, and role models. On receipt of her award in 2013, surgery resident Dr. Rita Mukhtar was recognized as a “phenomenal clinician and teacher who models extraordinary patient care and, even on a busy service, has an incredible way of making patients feel like she has all the time in the world for them . . . and took time to teach during night shifts and cases.” Dr. Mukhtar added: It’s taken me a long time to figure out what med students need. I agree with taking their feedback seriously, and remembering what it’s like to be a student. I’ve learned it’s important to remember to be kind, because they are under tremendous pressure. I try to make every opportunity a teaching one, for example, talk about the case before/after; explain how to write orders; use that to talk about fluids, urine output, and medications. I also have realized that some students really shine when they are given responsibility . . . so I try to promote them to intern status for their patients and actually let them make decisions (with supervision and within reason). This all takes a lot of time . . . but it makes a huge difference for the students.

Over the years, I noted those residents who distinguished

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Learn One, Do One, Teach One Continued from the previous page . . . themselves through exceptional teaching. Jennifer Ogilvie was the recipient of one of the most prestigious UCSF teaching awards and is now an endocrine surgeon and medical student clerkship director at NYU. One of her key recommendations is to harness those special opportunities known as the “teachable moment.” Unlike the classroom setting, clinical teaching is often done on the fly, in those unstructured and unplanned “teachable moments” without a clear plan or lesson: as in the cafeteria, or the OR front desk waiting for an operation to begin.

Another recommendation is to perform a lot of teaching early in one’s career; in some way quantity is more important than quality. Reflect upon the student feedback graciously (even if negative), which enables one to improve with practice.

For several years I directed the final course for the graduating medical students, where I learned this latter lesson personally.

In reflecting on student feedback, I realized that to effectively communicate while teaching, one needs to understand the perspective of your audience. The question is not what I think is most important looking back at my experience as a fourth-year student twenty years ago, but rather to see things from the perspective of a student now looking forward into the future, as their educational needs are very different.

I redesigned the course to respect their accomplishments and the challenges in their day, to lift them up and propel them forward.

Regarding student concerns: My course co-director began the course with the question, “What are a medical student’s greatest fears?” Her answers are harming a patient and looking foolish/being embarrassed at conference. The challenge for a resident is that while asking difficult questions can make the medical student better, it can generate student anxiety. So how to balance student education and stress? One solution is to ask easier questions, but perhaps the following advice I provided to third-year students during orientation helped to allay these fears. “The third year of medical school is a transition from the first two years of classroom teaching.

From now until the completion of training, you will probably be asked 7,000 questions. You’ll probably get about 4,000 right, and 3,000 wrong. To reassure you, medical education is not a contest where the goal is to answer every question correctly. Instead, it is the confidence and poise with which you respond that is being assessed, and perfected, to prepare you for much harder questions in the future, such as, ‘Was this undesired outcome the result of medical error?’”

In a 2008 paper in the Journal of Surgical Education, Drs. Doruk Ozgediz and Ramin Jamshidi (two exceptional UCSF 18 19

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resident educators) summarized the teaching challenges for residents. These include insufficient time, a lack of recognition of the value of teaching by residency programs, a lack of training in teaching, an insufficient fund of knowledge to teach, unavailability of students, fatigue, and a lack of motivation. They recommended using a “toolbox for time-constrained educators” to improve teaching, which include using teachable moments, role modeling professional behavior with other health care professionals, thinking out loud to help the students understand how a surgeon thinks, allowing the student to become the teacher and present to the team on a special topic, setting aside prearranged teaching time, and providing clear expectations for the student at orientation. They focused on meaningfully involving the student in the OR by dissecting the resected specimen and palpating the abnormal anatomy intraoperatively.

They also emphasized the value of a junior surgery teaching resident to serve as a teaching and mentoring resource, with possible roles in the education of nurse practitioners and pharmacists. Perhaps teaching residents can address other challenges to medical student education, namely loss of medical student roles (as NPs are often completing the tasks of note writing and order writing) and the disruption in continuity of teams as a result of work hours and sign-outs.

One tip when giving feedback is to use the RIME system:

R | A “reporter” accurately repeats factual information. Stating that the “temperature is 39.3” is the expected role of a student from the start to midway of the third year.

I | An “interpreter” is able to translate the abnormal tem-

perature to “the patient is febrile and septic,” an ability which students typically master around the middle of the third year.

M | A “manager” can state a plan of action, as “intra-abdominal sepsis is the likely source of the fever, and a CT scan and IV antibiotics are necessary.” This embodies the role of the intern.

E | An “educator” can teach in the context of the patient and state that “the incidence of intra-abdominal sepsis after Whipple resection reflects the texture of the gland and rate of pancreatic fistula.” This is a chief resident role, though a medical student can achieve this when delivering a specially prepared presentation.

To provide meaningful feedback, recognize the time of the academic year and where your student is ahead or behind along the RIME spectrum. As a resident, try to position your medical student to sparkle before the faculty and team. When a student doesn’t deliver a stellar case presentation, it might be because the student had insufficient time to prepare or rehearse with you. For those particularly interested in education, another strategy is to undertake advanced instruction in education, such as the UCSF Teaching Scholar’s program.

The first decade of 2000 has been focused on compliance with the ACGME resident work-hour restrictions. We now are www.sfms.org

presented with a key opportunity: The field of medicine has witnessed a blossoming of educational fellowships to determine how best to train residents, by promoting a competency-based curriculum and efficiency. I think this is an exciting time to redefine the paradigm of education. In his book Guiding Lights, President Clinton’s former speechwriter Eric Liu described the larger societal perspective of teaching. “Teaching is literally what life is all about. Passing it on. We teach to be sure that we have not lived in vain. We teach to learn.”

Teaching is indeed the future of medicine, by empowering the next generation of doctors and surgeons. Perhaps over his or her career, a current resident will become the next Abraham Flexner and unite the efforts of those individuals nationally dedicated to education to redefine and transform medical education to overcome the challenges in 2013.

John Maa, MD, FACS, is the president of the Northern California Chapter of the American College of Surgeons and chair of the University of California Office of the President Scientific Advisory Committee. He is also serves on the board of the SFMS. These comments were delivered at the International Women in Surgery Symposium in San Francisco in June of 2013.

Home Sweet Home Continued from page 15 . . . of our patients is truly appreciated.

Yet for all these tangible benefits, the greatest value of Housecalls has been for me the chance to learn more about my patients, their pasts, and how they view their futures.

With my ninety-year-old, soup-serving patient, I see her as a woman who loves and vigorously attends to the peppers in her garden; when she is no longer able to cook for others I will have a better understanding of her decline and hopefully be more sensitive to her needs.

The rotation has been well received by those who have participated in it, and it helps address a need described by residents. In a survey within our residency, nearly 90 percent reported an interest in improving their ability to care for geriatric patients. Yet less than one-third said they had had any geriatrics training, much less the opportunity to participate in Housecalls. This, to me, is sad. Visiting my patients in their homes has not only added depth to residency but has strengthened many of my patient-doctor relationships as well.

Housecalls has illustrated the rich variety of my patients and their lives, and in doing so reaffirmed my own commitment to medicine and primary care. All between bowls of soup.

Jeffrey K. Hom is a third-year internal medicine resident at UCSF and a member of the SFMS. He hopes to practice primary care and public health at the city and county levels. Thanks to Dr. Carla Perissinotto for her input and advice in the drafting of this article.

www.sfms.org

The Importance of Mentorship Continued from page 16 . . . earliest introduction and mentorship through medicine came from my African-American pediatrician. Our relationship over my lifetime fostered trust and strengthened my engagement in health. In his legacy I went on to graduate from his alma mater, Meharry Medical College. As I listened to my patient explain her experiences with devastating illness and personal tragedy, I saw an opportunity. I could have the same impact in her life that my previous mentors had had in mine. By the end of our visit, she was excited and invigorated to discuss her personal aspirations and goals. Her primary goal was to be healthy so that she could care for her children. The second was to have a career that would make her happy. At the core we shared the same goals. As a mother, professional, and a member of her larger community, I took the opportunity to tell her the obvious: “You are a great mother and a strong woman.” I commended her resilience and aspirations. I left the visit feeling proud to have provided the space necessary to expand our relationship beyond just a doctor-patient role but to also provide support and mentorship.

As a young African-American doctor, one of my greatest rewards is when I am able to serve as a role model for my patients.

Mentorship has been the foundation of my success. My role as a family physician provides the framework to give back to the community through patient care and mentorship. These experiences strengthen my faith that I am on the right path. Although I serve patients of all ethnicities and backgrounds, I feel an inherent responsibility to be a positive presence in the lives of my African-American patients. I understand now more than ever the importance of having physicians who are reflections of the communities that they serve.

LaKisha Garduño is a third-year family medicine resident at UCSF-SFGH. A Bay Area native, she grew up in Richmond, California, and is a graduate of U.C. Berkeley, where she studied molecular biology. Prior to medical school she worked in the fields of clinical research and science education. She received her medical degree from Meharry Medical College in Nashville, Tennessee. She currently lives in the East Bay with her husband and two daughters.

Resident Perspectives Rosemary K. | Internal Medicine/Preventive Medicine What was your most inspiring or challenging moment of residency? The most challenging moments for me have been and continue to be those times when we inform families that their loved ones will not survive despite maximum medical therapy.

How would you like to see medicine or your specialty change or evolve and why? I think two major changes on opposite sides of the care continuum need to happen. First, we need a more patient-centered, compassionate approach to end-of-life care. Public surveys have indicated a gap between what people say they want for end-of-life care and what is actually practiced in medicine. More opportunities for discussion about advanced directives and palliative care are necessary to close this gap. Second, we need to do better with chronic disease prevention. Changes in health behaviors need to be driven by individual risk assessments, prevention plans, and strategies for patient accountability.

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The Resident Experience

Access for the Insured A Resident’s Barriers to Obtaining Care Daron Williams, MD Transitioning from medicine intern to upper resident affords many new opportunities, not the least of which is moonlighting. Contemplating a career in hematolo-

gy-oncology, I jumped at the chance to spend a weekend working on the inpatient leukemia service. Saturday morning I arrived early to briefly review my patients’ charts. Coverage that day would be sparse, so it was not surprising when there were more than the usual number of inefficiencies. By midday Sunday, our team’s work flow had greatly improved. It was exciting to consider how much better prepared I would be for future moonlighting shifts.

Yet nothing could prepare me for my subsequent inpatient stint, for the next time that I set foot on the leukemia ward it would be not as a physician but as a patient.

Looking back at the weekend spent moonlighting, it’s evident that my disease had already begun to manifest itself. While I was still able to bike from one hospital to the next and work shifts lasting up to thirty hours, it was increasingly difficult to make it through each day. I was excessively fatigued, and my ankle was painfully swollen. Sensing that something was wrong, my then fiancée (and now wife) urged me to have my cell count checked. I initially resisted her suggestion but ultimately conceded. We were reassured by the absence of circulating blasts, although the CBC did reveal a mild anemia and lymphopenia. These deviations, we assumed, could easily be attributed to a run-of-the-mill viral syndrome. There was nothing to do but carry on with residency and life as we knew it.

Over time, symptoms continued to accumulate. A minor trauma sustained while playing basketball resulted in disproportionate rib pain; an achy hip interfered with an otherwise pleasant walk; and my favorite foods lost their appeal. My primary doctor checked more labs, which again showed similar nonspecific abnormalities. Then an unusual rash appeared, followed almost immediately by the emergence of a hard, immobile, anterior cervical lymph node. At that moment I feared the worst. Skin and lymph node biopsies confirmed my suspicion that my symptoms were caused by a hematologic malignancy. My life, and the lives of those around me, would never be the same.

Receiving a diagnosis of acute lymphoblastic leukemia (ALL) instantaneously shifted my role at the hospital from physicianin-training to physician-as-patient. My white coat, suddenly obsolete, was replaced by a patient gown. It was surreal to see my coresidents on rounds whenever I left my room. Passing them in the hall, I wondered if I would ever resume my medical training.

Now, more than eighteen months from the time of my diagnosis, though I continue on an arduous journey, my dream of returning to the practice of medicine is beginning to take shape. Reflecting on my experience, numerous episodes stand out—many of which relate to the hurdles that patients must overcome to optimize 20 San 21 SanFrancisco FranciscoMedicine Medicine September September2013 2013

their medical care. Many consider that the greatest deficiency in our health care system is limited access for the uninsured. Yet it is less often recognized that having insurance, though a necessary first step, is not sufficient to obtaining excellent care. Upon being diagnosed, we questioned whether I could receive the best possible treatment at the hospital in which I was admitted. We expected that there would be a single, proven chemotherapy regimen that was the standard of care for ALL. In reality, numerous regimens are used, few of which have been compared in head-to-head trials. Thus treatment selection is unduly influenced by factors other than efficacy, including regional variation and institutional bias.1 We were offered treatment with a myeloablative chemotherapy regimen that was developed locally, validated in a trial that began in 1987, and described in a single peer-reviewed article.2 After consulting outside experts, it was apparent that although this regimen is composed of a combination of drugs similar to those featured in other plans, it is not widely used. We considered moving to another hospital but found that transferring out of state is prohibitively expensive. My insurer, for one, generally only covers care provided by specific California hospitals. Moreover, had we transferred, maintaining insurance coverage by agreeing to a clinical trial, my wife may have lost her job and our only remaining source of income. Faced with a paucity of choices, we agreed to the treatment regimen that was initially offered to us. Access to care was realized, but not with the degree of choice that one desires when making a life-altering decision.

Soon after starting treatment, my access to optimal medical care was threatened in other unexpected ways. Drug shortages, we learned, are a persistent problem for patients undergoing chemotherapy. In my case, preservative-free methotrexate (PF-MTX), a mainstay of my protocol, was in scarce supply. As an alternative, I was offered treatment with a methotrexate preparation that contains a potentially toxic preservative. Fortuitously, a few days before I was scheduled to receive the high-dose infusion, several grams of PF-MTX materialized, and I was liberated from having to make the precarious choice between an indefinite treatment delay and exposure to the preservative. Many patients, however, are less fortunate, and their access to first-line chemotherapy agents is limited.3 Being a resident, I was sympathetic to the inevitability that some of my care would be provided by less experienced clinicians.

But trainees are not always given adequate instruction prior to working on the leukemia service. Late one evening, I felt a sudden queasiness, ran to the sink, and vomited frank blood. Upon arrival of the on-call resident, my stomach discomfort had resolved. We chatted briefly, and as he got up to leave I realized that the resident had not taken into account my platelet count of less than 10,000

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The Resident Experience

RESIDENT WELL-BEING Taking Care of Our Health Too Hetty Eisenberg, MD, Eric Chang, MS3, David Elkin, MD Amid the countless hours of formal training, medical education has been noted to foster an implicit curriculum. This implicit curriculum shapes trainees to be-

come both great doctors and great human beings. However, the culture of medicine has not always supported residents’ healthy development. As physicians in training, we are given the message not only that we are separate from our patients but also that we are separate from humanity, as posited in a 2011 Lancet editorial.

Many students begin this process in medical school, during which time it has been shown that they begin to lose their capacities for empathy, a natural human quality that connects us to our patients and other human beings (Newton 2008). As students and residents progress further along in training, we may lose contact with our own selves as well, as personal mental health may take the backseat to professional development.

We may witness stigma against mental illness and sometimes experience barriers to seeking help (Center 2003).

In recent years, there has been growing awareness of the impact that physicians’ ill health can have upon health care systems, as well as of the unusually high rates of psychiatric morbidity in physician populations, including suicide (Wallace 2009, Schernhammer 2005). Out of this awareness, greater attention is being paid to the importance of physician well-being (Clever 2002).

Physician wellness has traditionally been defined as the absence of burnout, characterized as “the loss of emotional, mental, and physical energy due to continued job-related stress.”

Physicians have been found to have much higher rates of burnout compared to that of the general population, with the onset of burnout linked to residency training (Rosen 2006).

In the review by McCray et al, which summarized nine studies of resident and medical student populations, the authors noted that “the prevalence of burnout appears to be highest among resident physicians” (McCray 2008).

This chronic exposure to stress during residency is accompanied by significant psychiatric morbidity (Saadat 2010).

Burnout is strongly correlated with clinical depression, with residents demonstrating two to three times the rate of depression found in the general population (Purdy 1987, Lemkau 1988, Shanafelt 2002, Lefebvre 2012, Thomas 2004, Saadat 2010, Martini 2004). Other significant psychiatric comorbidities of burnout include anxiety, insomnia, substance abuse, impaired cognition, impaired learning and memory, impaired www.sfms.org

personal and professional relationships, and a host of poor physical health outcomes (Willcock 2004, Eckleberry-Hunt 2009, Lefebvre 2012, Saadat 2010, Shanafelt 2002).

Burnout can be all-encompassing and often impacts multiple domains of functioning, including the physical, intellectual, emotional, social, and spiritual. Burnout can lead to feelings of powerlessness, hopelessness, resentment, and failure, as well as reduced productivity (Saadat 2010) and possibly increased medical errors. Lack of control is an important factor, and, as Thomas et al explain, “Resident physicians have tremendous responsibilities in the workplace yet may feel they control very little. This arrangement sets the stage for residents to develop burnout” (Thomas 2004). Other factors that have been hypothesized to contribute to burnout include high financial debt, long work hours, gender, status as parents, acculturation status, specialty, age, marital status, perceived social support, perfectionism, lack of coping skills for stress, substance use, lack of time, difficult and complicated patients, excessive paperwork, lack of exercise, cynicism, and regret over chosen career.

Notably, neither demographic nor personality characteristics appear helpful in identifying at-risk residents.

Considering the long hours worked by residents, it seems logical that duty hours would be correlated with burnout, and that duty-hour reform would help prevent burnout (Guerts 1999). However, 40 percent of residents in one study continued to demonstrate high levels of burnout after work hour limits were instituted. Findings suggest that duty hours per se often fail to encompass the additional hours of studying, note writing, and presentation preparing that residents are required to complete as part of their training (Lefebvre 2012). Thomas et al suggest that resident burnout may not be correlated as much with duty hours as it does with the intensity of the workday and the extent to which the workday interferes with residents’ home life.

Although resident work hours and sleep deprivation are associated with stress and medical errors, in the studies examined, sleep deprivation was not found to be associated with burnout, nor was restricting work hours alone associated with a reduction in burnout. Rather, the intensity of the resident’s workday and the extent to which that intensity interfered with the home life of the resident was repeatedly associated with resident burnout. These studies suggest that residency programs might begin to improve resident well-being by restoring meaning to residents’ time commitments, facilitating supportive social interactions, increasing resident work control, and promoting the separation of work and home life. Translating these qualitative concepts into practical strategies will be an

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Resident Well-Being Continued from the previous page . . .

Access for the Uninsured Continued from page 20 . .

important challenge (Thomas 2004).

Thus, while duty-hour reform is one way to address burnout, promoting well-being through resident wellness programs may have advantages over duty-hour restrictions. Some of these potential advantages include being without controversy, fostering interactions between faculty and residents, flexibility that facilitates initiatives to be tailored to individual resident populations, offering support and education, and averting crises (Lefebvre 2012).

Although there are a number of university-wide and medical school wellness programs, and UCSF has both, there are few programs that are either dedicated to serving the mental health of residents in particular or are structured to meet this population’s unique needs (Pitt 2004).

The University of South Florida previously reported on a wellness program that is residency-wide across forty-six training programs. The program involves extensive counseling services specially designed to be easily accessible and confidential for residents, focusing on both “big” and “small” issues and serving to facilitate debriefings for residents after significant events (Dabrow 2006). The University of Alberta Emergency Medicine program has a resident-designed resident wellness program that includes four key components: providing a safe office for residents to express grievances; ongoing surveillance of residents, including mandatory, regular one-on-one meetings with residents that are specifically designed to uncover symptoms of depression, burnout, and substance use; lectures, workshops, and exercises to actively educate residents about the pitfalls of burnout and habits of wellness; and initiatives that target domains of physical, mental, social, intellectual, and community wellness, including gym access, resident retreats, social outings, mentoring, and charitable donations (Lefebvre 2012). Other programs have focused on improving coping and using meditation exercises to manage stress. However, residents need time to attend these exercises, and thus they may favor more efficient residents who may be experiencing less burnout already.

In summary, resident well-being is an important goal for all residency programs and lays the emotional foundation that will last over the course of any physician’s career. Achieving that goal remains a balancing act, with the investment required for well-being programs competing with ever-increasing responsibilities of residency training. The focus of these programs continues to evolve, moving beyond the absence of burnout to the active promotion of resident wellness. The promotion of these programs suggests a cultural shift may be eminent, in which resident well-being could be considered a critical component in the provision of effective and compassionate care. A focus on resident wellness may not only better address the underlying components of resident well-being but also advance our profession’s ideals for patient care and the promotion of wellness, instead of the minimization of disease.

platelets/μL. After I pointed out the profound thrombocytopenia, he ordered a platelet transfusion and the bleeding stopped. A potentially bad outcome was averted, but if the patient had been a layperson, unaware of the lab abnormality’s significance, would he have had the same result? I’ve often wondered how frequently provider inexperience limits health care quality. After four grueling cycles of chemotherapy, my disease was in morphologic remission but remained detectable by flow cytometry. Persistence of “minimum residual disease” portends a poor prognosis,4 so we elected to do an allogeneic bone marrow transplant. My sister was a perfect match and an eager donor. I completed a conditioning regimen of chemotherapy and total body irradiation, then received an infusion of her stem cells. After weeks of waiting for the cells to engraft, I was discharged home with a plan to follow up frequently in clinic.

Navigating the health care system as an outpatient has many challenges. Shortly after returning home, I developed pain and weakness in my lower extremities. I asked for a referral to neurology, which per my HMO had to come from my primary doctor, not my oncologist. With the referral in hand, I called the neurology clinic. The woman who answered said that the first available appointment was in two months. Fearing that in two months I would be unable to walk, I e-mailed the neurology attending who had previously consulted on me in the hospital. He forwarded my e-mail to a neuropathy expert who agreed to see me the following week. As part of my evaluation, the neurologist ordered an MR neurogram and told me that someone from radiology would call to schedule the study. After weeks passed and still I hadn’t been contacted, I called radiology scheduling and was placed on a seemingly interminable hold, until finally I reached a receptionist who said that their earliest opening was several weeks away. In fairness, on the day of the exam the imaging center ran on time, the technologists were professional, and the test was done correctly. Regrettably, I have found that deterrents similar to those that I encountered while pursuing the neuropathy evaluation are nearly ubiquitous when scheduling clinic visits, labs tests, or imaging studies.

Now more than a year since my transplant, the leukemia is in remission—undetectable by both morphology and flow cytometry—and my neuropathy is slowly improving. I am grateful to all of the practitioners who have helped me recover, but often I wonder where I would be if I hadn’t used my privileged position as a medicine resident to access the health care system. The most enduring lesson that I have learned over the course of my illness is that every patient must advocate for himself; of course, that’s easy for me to say, considering that my wife, a pediatrician, has been the strongest advocate a patient could ever dream of having. The debate surrounding the Affordable Care Act grinds on, and it is important to acknowledge that expanding health insurance, while important, does nothing to address the numerous hurdles faced by insured patients. As the day approaches for me to again don my white coat, I ask myself what I can do, both as a patient and as a physician in an extensive network of payors and providers, to improve access and optimize health care for all.

Daron Williams, MD, is an internal medicine resident at the UCSF currently on leave as he recovers from leukemia treatment. His goal is to resume medical training as a pathology resident. References are available online at www.sfms.org.

Hetty Eisenberg, MD, is a recent graduate of UCSF Psychiatry Residency; Eric Chang is a third-year medical student at UCSF; and David Elkin, MD, is a psychiatrist at SFGH, clinical professor at UCSF, and head of the SFGH Physician Wellness Committee.

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The Resident Experience

ACGME Duty Hour Reform Unexpected Side Effects Claudia Diaz Mooney, MD Completely exhausted after a twenty-four-hour labor and delivery call, I completed the final suture in the perineal repair. My fatigue was overwhelming as I pre-

pared to leave the hospital. I walked to my car and began the drive home—excited to finally rest in my own bed after a long call. I recall opening the windows, blasting the music, and drinking coffee while sleepily crossing the Bay Bridge—hoping that I would not fall asleep at the wheel. Nonetheless, I felt a sense of accomplishment after having been present with several families for the delivery of seven babies over the last twenty-four hours, including a twin delivery.

Throughout the last decade, the Accreditation Council for Graduate Medical Education (ACGME) has made duty-hour changes to help with resident fatigue. In 2003, the ACGME implemented an eighty-hour workweek duty requirement for all U.S. residency programs. Since then, a significant improvement in patient safety and resident well-being has not been clearly demonstrated.1,2 Starting in July 2011, residency programs were further challenged to modify their residents’ schedules to accommodate new ACGME duty-hour requirements. The proposed changes theoretically provide several benefits to resident physicians, including mitigating fatigue, enhancing trainee supervision, and improving transitions of care. One of the most controversial and significant changes called for “duty periods of PGY-1 residents not to exceed sixteen hours in duration.” A proposed benefit of this change was the potential for less-fatigued interns at work translating into reduced medical errors, and improved patient care and resident well-being. As a response to the 2011 duty-hour requirements, residency programs implemented shift work and increased patient hand-offs. These modifications have brought about unexpected side effects: communication errors due to increased patient hand-offs, reduced continuity of care, and decreased quality of patient-physician relationships.

A statement by the British Medical Journal explored concerns regarding increased patient hand-offs: “ . . . many junior doctors working more frequent, albeit shorter, on-call shifts. . . . Such systems reduce continuity of patient care and increase the risk of adverse incidents.”3 Studies have reported that preventable adverse events are twice as likely to occur during periods of patient crosscoverage.4,5 In 2003, the Joint Commission reported that the root cause of 70 percent of all sentinel events is due to a breakdown in communication.6 Furthermore, studies have shown that 60 percent of medical residency programs have not provided training on hand-off skills.7 A retrospective study after the implementation of the duty-hour requirements of ten hospitals in North Carolina found medical errors remained common.8 Given these findings, it is imperative that residencies put more emphasis on standardwww.sfms.org

izing hand-off techniques. Recommendations and curriculum around patient hand-offs has been developed since the advent of the new duty-hour requirements. In our residency program, we have instituted a designated sign-out time and location (ideally free of interruptions) and incorporated both a standardized written and verbal sign-out. Despite establishing these guidelines, we have still been met with trainee communication challenges during the process.

Other concerns are also raised as a result of the reform. Residency is an intense training period during which nascent physicians struggle with learning the intricate details of medicine and balance that knowledge with daily patient interaction. It is also a time when one can build meaningful relationships with patients.

Does spending less time on hospital shifts mean checking off more “to-do boxes” and less time at the bedside assessing what a patient really needs? If so, than patient-physician connectedness may be suffering as well. Shorter workdays may lead to a decrease in continuity of care and negatively impact the quality of patient-physician relationships. A 2007 national survey of key clinical faculty at thirty-nine internal medicine U.S. residency programs revealed that the faculty reported worsening in the continuity of patient care provided by residents (87 percent), residents’ communication with patients and families (66 percent), and overall quality of patient care (60 percent) as a result of duty-hour limitations.9 A partially randomized cohort study of residents and hospitalist attendings on general pediatric inpatient teams investigated the effects of a resident schedule compliant with the 2011 duty-hour requirements. The intervention group included interns who adhered to a shift-based schedule proposed by the 2011 duty-hour requirements versus the control group who continued the thirtyhour call schedule and Q4 call days.

On the topic of professionalism, both interns and attendings in the intervention group rated survey questions lower than the control group. These questions addressed patient ownership, resident relationships with patients/families, and residents’ abilities to place patient’s needs above oneself. This study concluded that increased work compression seemed to be a significant contributor to the decrease in resident well-being.10 In this new culture of frequent transitions of patient care to allow resident physicians time away from the hospital, patient-physician relationships are being affected. In sum, we may be inadvertently developing a less patient-centered environment in this new era of new-duty hour restrictions. For many of us, human connectedness led us to a career in medicine and is what keeps us going. Forming and building relationships are at the core of practicing medicine. When training residents, it is important to be mindful that these relationships are vital. The ACGME duty hour reforms have been key in advocat-

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The Resident Experience

Serving the underserved A Resident Finds Her Passion Kyle Meehan, MD Throughout my residency at San Francisco General Hospital, I have cared for marginalized people and some of the sickest inhabitants of San Francisco. Many

of my patients are uninsured, many are homeless, and many are struggling with mental illness and addiction. I have been asked by friends, physicians who work in very different settings, and even strangers why I chose to work at the county hospital and safetynet clinic. Often the answer to this question is hard to articulate, because it’s what I’ve always wanted to do. For people who have not experienced this work, it seems foreign. But, as I think back on residency, I think of my days bookended by journeys: the walk to the hospital anticipating the patients I would see that day and the colleagues with whom I would interact, and the walk out of the hospital after a long call night or a busy emergency department shift. Each evening, I spent this walk reflecting on the day’s patient encounters and, each morning, on my hopes for the new day.

A few months ago, I was finishing a shift early in the morning just after dawn and began my walk home exhausted and devoid of energy. I saw a man in an electric wheelchair, homeless and disheveled, a 40-ounce beer in hand, charging his wheelchair on the outside electrical sockets around the corner from the Emergency Department. Beams from the rising sun gently hit him, the first touch of warmth in that day, breaking the cold of the San Francisco night. No one else was around. In that moment, I realized what my place of work is for so many of our patients—it is a place where, literally and figuratively, people come to recharge, to regroup, to plug in. And, it turns out, it is the place where I come to do the same. It is these patients who recharge and fill my cup. It is at this place that my deepest gladness and the world’s greatest hunger meet.

In fact, it was in almost this exact location in the hospital driveway two years prior that I met with one of my patients threequarters of the way through a 24-hour labor and delivery call. I had already delivered two babies during the daytime portion of my shift. Things had calmed down and I was heading home hoping for a few hours of sleep before signing out in the morning. As I was leaving, under the flickering streetlight near the bus stop outside the hospital, I could barely make out a waddling pregnant woman making her way from the end of the driveway near the Emergency Room turnaround. By the time I was fifty yards from the woman, I recognized her as my patient. I turned around and escorted her and her sister to the labor and delivery floor. We confirmed that she had ruptured her membranes and was in active labor. Four hours later, at dawn, I was coaching this patient through the delivery of her baby. In between pushes, her sister kept saying, “Doctora, I know you from somewhere.” As it turned out, my patient’s sister worked at UCSF-Parnassus, but as a family medicine resident we do not rotate through that hospital. We ran through all of the ways that we could know one another, including wondering if 24 25

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we could be neighbors. As the baby was crowning we abandoned this guessing game to focus on the joyous arrival of her niece. My patient delivered a beautiful baby girl.

As her family members filtered in to take pictures, say blessings, and give congratulatory hugs, I slipped out to write the delivery note. At that moment, my patient’s nephew, only ten years old, came running past me but then abruptly stopped, looked at me, and then turned to his mother. “Mami, that doctor was the one there when Abuelo passed. She was the doctor who held his heart and listened to see if God had taken him yet.” With that, my patient’s sister, this observant young man’s mother, shuffled him in to give kisses to his new cousin, and then she came out to see me.

She said, “Doctora, this is how I know you. You have taken my family from life into death and back into life.” We were both at a loss for words, our hearts swelled, our eyes teared, and we embraced.

In that moment, all of the continuous hours awake on call disappeared.

All that was left was the deep understanding that this family had permanently changed me and I them, that our paths were crossed, and that being a part of their stories in fact defined me as a family physician. This family and other families like them, and the hospital that has trained me, have been my power source. This energy is what brings me back up that driveway into the doors of San Francisco General Hospital every day.

Kyle Meehan completed her residency at the UCSF-SFGH Family and Community Medicine Residency Program, where she stayed this year as chief resident. She hopes to continue working with an urban underserved population and is particularly interested in maternal child medicine, integrative medicine, and academic medicine.

ACGME Duty Hour Reform Continued from page 23 . . ing for improvements in resident fatigue by limiting work hours.

However, along with these obvious benefits there are also challenges, including an increase in patient hand-offs and a decrease in continuity of care. Studies and anecdotal evidence have shown that these changes can negatively impact patient-physician relationships as well as create different types of medical errors. These adverse effects have an impact on resident well-being and work satisfaction and should be more closely examined. It is now up to us to continue developing new formulations of teaching humanity in medicine in an ever-changing system so that we can avoid these unexpected side effects of the duty-hour reform.

Claudia Diaz Mooney completed her residency in 2012 at the UCSF/SFGH Family and Community Medicine Residency Program and her chief residency in July 2013. References are available at www.sfms.org. www.sfms.org

The Resident Experience

Awakening in the ICU Getting to Know Your Patients Kim Nguyen, MD “When in your life you feel stress, or pain, or a need for comfort, talk to God. Say to Him, ‘I don’t know you, but you know me.’”

In a place where we’re told we are to heal people, this is told to me by a woman whose husband had suddenly collapsed from an enormous heart attack (a bystander at a grocery store gave him CPR). She is sitting by his bedside, and I’m kneeling next to her, even before the mention of spirituality, because there’s no other chair and it doesn’t feel fitting to stand while speaking with her about the possibility that he may not wake up, and that if he does, he may not be who she remembers.

Who that person is whom she’s waiting for to awaken, I don’t know.

The thing I anticipated being the hardest about the ICU was not knowing the patients. Many of them are intubated, others are completely unresponsive; if a patient is awake, he or she is most likely delirious. It can be days or weeks of taking care of someone before you have a conversation. You get to know their ventilation settings, their heart rhythms, and how much they urinate over twenty-four hours, but what their voice sounds like? The strength of their handshake?

How their face transitions from asleep to awake (an intimate privilege of being an intern who has to wake patients at predawn to ask them how they’re feeling, as though this is supposed to further their well-being)? A mystery. I anticipated this, and this was true.

What I didn’t anticipate, which is equally hard, is a sense of losing myself in the ICU and a quiet sense that the patients, in all their silence and in all their perceived handicap that makes it so that the medical system is keeping them alive, know me better than I can know myself in this unit of intensive care.

Earlier this year the interns listened to a physician speak about experience as a patient in the ICU. He could vividly remember how much it meant to have his hand held by a medical student, how nurses would criticize the bumbling interns, and generally his environment, with clear eyes that we normally assume can’t perceive because the patient can’t move, can’t speak, or can’t express in a way we understand.

In the ICU, I think of this, and when I am so worn out by the work—a combination of having to do a lot of busy things like answer pages, write orders, and write more orders, and of having very sick patients and very little sense of what to do for them—I think of how these patients see me. They must see the postures of my back before I feel my muscles ache, and hear the edge in my voice when having to deal with things I don’t want to, before I come home and finally have enough room to realize how frustrated I am. They must see too how www.sfms.org

little time I spend with them, how I don’t learn what little I could know of their faces because instead of sitting in their rooms I am standing outside at the computer looking at their lab values and blood culture results, because at the end of the day my higher power is an attending physician who will want to know what a patient’s bicarb was that morning, and two minutes ago.

We are trained to “know” our patients, to be so consumed by this aspect of care, that I have little space to remember that I don’t really know them, and that this mind-set keeps me from knowing myself. Even though I’m not religious, I do believe in something that does know. Being in the ICU, I feel that this something lies within these people, these people who are the focus of our observation but are the true observers. And it’s to them that I should come when I want to find answers.

This isn’t the place for me to present myself as someone who knows. The ICU is an incredible place to learn about human physiology and about the extraordinary measures we have devised to manipulate it, and I value that knowledge I’ve gained.

But more than learning the machines and monitors and IV drips that crowd this space, I receive the most from feeling the emptiness of not engaging in everything else.

Kim Nguyen, MD, is a second-year resident in the San Francisco General primary care track of internal medicine at UCSF.

Resident Perspectives James T. | Internal medicine I was working nights on the inpatient cancer ward, and I had just started a shift. The results from a blood smear had returned on a patient who had been admitted to the hospital that afternoon. She had been hospitalized before and received aggressive chemo to which she had responded well. She came back to the hospital because she was tired and outside labs showed worsening anemia.

A drop of her blood was placed between two pieces of glass and smeared into a thin layer. When the pathologist looked under the microscope and saw that the smear was full of blasts, she made a notation in the electronic record: AML, relapsed. A drop of blood is worth a thousand words, I suppose. But we only needed one and a couple of letters.

When I told her, she already knew by the way I opened the door. Her resilience and acceptance were admirable and heartbreaking. It would have been easier to bear if she had been angry and resentful. Because then she would have been like me.

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The Resident Experience

Book Review Stories from Female MDs Erica Goode, MD When the Personal Was Political: Five Women Doctors Look Back

By Toni Martin, MD | iUniverse, 2008

This is a succinct, well-researched work, laced with wry humor, which starts with the premise that providing women physicians’ stories (Toni

Martin’s, mine, and those of three other classmates), and explaining what we faced as part of a group of forty minority members of our class of 146, would highlight the multiple issues that will always plague women in an intense worksite such as medicine. Beyond that, it provides the history of those times, as we washed up on a later wave of 1960s “women’s liberation.” Martin discusses all of the following issues in her book; these words are mine, since I was there.

In 1973, we met the early backlash and fairly intense sexism of that time—even though UCSF was, then, ahead of most medical schools in terms of minority admissions (including women). We benefited from its unusual policy of admitting a rich mixture of black, Latino, and other “out of the mainstream profile” types (a longshoreman’s son; a “first Indian” Nez Perce fellow; two “older” Peace Corps volunteers; and me, a superannuated thirty-three-year-old student). Martin, as a minimally pigmented “black” student, was, like me, a “twofer.”

I am certain that few male attendings and/or professors were even aware of their inherent biases; when Martin provided a review of her book at a 2008 UCSF noon conference, I watched the face of Holly Smith, MD, the chief of medicine during our student years. He appeared mildly incredulous at her assertions regarding the sometimes subtle, often overt responses of male physicians to us, the women. (Smith was not one of the offenders.)

Our spontaneous response was to form a women’s group of five to six people, who met regularly during the preclinical years. This helped immeasurably as we studied and commiserated together. Indeed, we were the prototype of the later UCSF small-group iteration of six students that exists today.

In 1973, we invented this group concept to keep mind, body, and spirit afloat while we drove ourselves to prove our worth as future physicians. During those clinical years we were harassed intellectually and sexually, usually in isolation.

(Our male classmates were invariably allies, to the extent that competitive beings can be.) We found our occasional gatherings essential to our survival.

As Martin states, most of the tiny group of women educators and preceptors at UCSF in our time were of little help.

They had no choice but to be rigid, exacting, and at times brutal in their pursuit of medicine and its teaching methods. She calls these women the pioneers, and we, the landing party— www.sfms.org

landing on relatively hostile or simply clueless shores, not designed to cope with these “other” doctors, especially if they— we—wished to alter the landscape.

This bias against women and minority students at UCSF has largely evaporated, as I see it. In 1990 I asked one student whether there was a “women’s group” and she simply responded with, “What for?” This is good.

Nonetheless, we five have continued to meet ever since.

We all still practice, thirty-three years after completing residencies, passing boards, and becoming leaders in various ways particular to our skills. Later gatherings featured discussions of our shared angst regarding the fancy footwork required to deal with husbands, kid care, household issues, talks and publications, finances, sleep deprivation, and the business of building and maintaining our medical endeavors with no “wife” to back us up.

For her book, Martin has harvested statistics regarding women’s issues in medicine from a wide variety of sociological and other sources, including Schulman, The Seventies: The Great Shift in American Culture, Society, and Politics; Kaltrieder’s Dilemmas of a Double Life: Women Balancing Careers and Relationships; and Levinson’s article “When Most Doctors Are Women: What Lies Ahead,” Annals of Internal Medicine, 2004.

These and other background works provide statistics regarding women in the workplace, the pervasive effects of once being in the minority, and the ongoing issues of being perceived by patients and peers as “more collaborative, willing to share time, be a friend perhaps, to be called by first names without asking, and by some to be perceived as less authoritative until proven otherwise.” All of these sources highlight many differences in ways that men versus women have been able to operate in the world of medicine.

As Kevin Grumbach, MD, chair, UCSF Department of Family and Community Medicine, wrote in his review of Martin’s book, it is “a must-read for anyone interested in understanding how far women in medicine have come and how much farther they have to go.”

Erica T. Goode, MD, MPH, currently practices internal medicine at St. Mary’s Hospital. She was a member of the UCSF class of 1977. She is a longtime member of the SFMS and serves on the Editorial Board.

September 2013 San Francisco Medicine

27

MEDICAL COMMUNITY NEWS KAISER

SFVAMC

UCSF

Robert Mithun, MD

Diana Nicoll, MD, PhD, MPA

Michael Gropper, MD

There is no doubt that the field of medicine, and more broadly health care, is in a state of flux. With the implementation of Federal Affordable Care Act (ACA) in full swing and the California State Exchanges ready to enroll participants by October 1, there is a reevaluation of how to practice medicine and deliver health care, while we are still actively doing both. In other words, the train is moving and we’re still building the tracks and determining the route.

While the ACA sets forth a model of care that calls for integration across all mechanisms of the delivery system, familiarly known as Accountable Care Organizations (ACOs), Kaiser Permanente is already designed as an integrated model, with our health plan, hospitals, and medical group well established and connected for decades.

There are myriad benefits to our model of integration, including electronic medical records that connect both inpatient and outpatient information, access to specialty care during primary care appointments, and a research database that includes tens of thousands of records.

For physicians who choose a career at Kaiser Permanente, the benefits of working for the largest private provider group in the country include seamless communication with colleagues, access to and inclusion in Kaiser Permanente research projects, and leadership opportunities within the organization. Physicians who work for Kaiser Permanente often comment that they are able to practice medicine as they intended, as they don’t have the concern of managing a small office or dealing with insurance companies.

With this ease of practice comes more time for discussing prevention and wellness with patients, focusing on culturally competent care, and chronic disease management— all cornerstones of our medical practice at Kaiser Permanente. Sometimes patients don’t even have to come to our offices to reap these health benefits, which saves them co-pays and transportation costs and prevents disrupting their busy day.

An article recently published in JAMA: Internal Medicine suggests that most people who live into their nineties are going to be dependent on others for daily care or have difficulty walking short distances in the two years prior to death.

In the study, “Disability and Difficulty Walking Two Years Before Death Is Common: People in Nineties and Women at Greatest Risk,” lead author Alexander K. Smith, MD, MPH, a San Francisco VA Medical Center physician, and his colleagues examined interviews with 8,232 people who died while enrolled in a national study of people over age fifty. In that study, 50 percent of people who died in their nineties required assistance from a caregiver to perform basic daily activities such as dressing, eating, or bathing. Over three-quarters needed assistance in their last month of life. Regardless of their age at death, 69 percent had trouble walking several blocks two years before death, and 82 percent had difficulty climbing several flights of stairs.

The study suggests our current health system is largely unprepared to meet the explosion of people living with late-life disability, as is occurring now with aging baby boomers. Despite being able to delay the onset of disability, the medical profession has not yet been able to prevent it.

A secondary finding was that women are more likely to be disabled than men two years prior to death, likely—per the study— because women are prone to disabling health conditions due to differing body compositions, and older men are more likely to have a spouse care for them, whereas older women are more apt to be widowed.

In addition to preventing disability, there needs to be a focus on providing support to patients already presenting with difficulties engaging in daily-life activities.

28 29

San Francisco Medicine September 2013

The recent rollout of the Accreditation Council for Graduate Medical Education’s (ACGME’s) Next Accreditation System (NAS) has created substantial excitement but also substantial anxiety and concern. The goals of NAS are to create a system that focuses more on training outcomes and less on process.

Of the NAS’s several components, the most innovative may be a new element called the Clinical Learning Environment Review (CLER). CLER visits are periodic site visits to sponsoring institutions and major teaching sites to assess each clinical setting for the “quality and safety of the environment for learning and patient care.” The CLER concept is based on growing literature that suggests that the quality of the clinical setting not only affects the quality of care in the present but also impacts the quality of care provided by trainees when they practice independently.

At UCSF, much of our long-standing work on resident engagement in institutional and departmental quality improvement efforts; our work on resident supervision, handovers, and duty hours; and our strong commitment to equality of care and care of the underserved position us well for these visits.

An ambitious attempt by the ACGME to respond to the public call for greater accountability in GME, the NAS is also an attempt to provide close oversight to programs and institutions that are having difficulty while giving more flexibility to programs with highquality outcomes. High-performing programs and institutions will have relaxed process standards and greater opportunities to innovate. I’m pleased to say that UCSF is extremely well positioned to be in this latter group.

Information for this column was provided

by Bobby Baron, MD, associate dean for Graduate and Continuing Medical Education at UCSF.

www.sfms.org

St. Mary’s

CPMC

Robert Weber, MD

Michael Rokeach, MD

Sutter Pacific Medical Foundation Bill Black, MD, PhD

Before I begin my first column as the new St. Mary’s chief of staff, I’d like to acknowledge Dr. Peter Curran, our outgoing chief. Dr. Curran has moved to the East Coast, and his leadership to our entire medical community will be missed. I appreciate his guidance and support during my transition to this new post. In addition, please welcome Dr. Carl Bricca as St. Mary’s new vice chief of staff. It is fitting that the theme of this month’s magazine pertains to residents, because both Dr. Bricca and I are homegrown, locally-sourced products. The St. Mary’s residency program has been a big part of our hospital since the program’s inception in 1904, and it’s vital to our ability to expand our reach while producing quality physicians that serve our community.

Our three residency programs—internal medicine, orthopedics, and podiatry—all connect quality training with patient care while fulfilling St. Mary’s mission of providing health care to the entirety of San Francisco’s ethnically and socially diverse population. Under the supervision of program director Dr. William McGann, St. Mary’s Orthopedic Residency Program is a fantastic example of the benefits such a program can have on an entire community.

St. Mary’s has a relationship to provide care for the clients of the San Francisco Department of Public Health and several other community agencies, including the Shanti Project, Delancey Street Foundation, and the Tenderloin AIDS Resource Center. Members of St. Mary’s internal medicine residency program, headed by Dr. Terrie Mendelson, and the podiatry program, led by Dr. William Jenkin, play just as vital a role in contributing quality health care to our community, serving on hospital-wide focus groups such as the Sepsis Task Force and Quality Improvement. By contributing in this way, the residents are helping foster policy and programs toward standardizing excellence in the service of patient care, while minimizing patient risk. And just as crucially to all of us, our residents are at the center of serving patients at the Sister Mary Philippa Health Clinic, located at St. Mary’s. www.sfms.org

Dr. Vernon Giang has been appointed as CPMC’s next chief medical executive, succeeding Dr. Allan Pont. Dr. Giang is a graduate of U.C. Davis School of Medicine and completed his residency in internal medicine at CPMC. While a resident, he won both the Francis Rigney Award as outstanding intern and the Dwight Wilbur Award as outstanding graduating resident. Dr. Giang has been a hospitalist at CPMC since 1996, and he currently serves as medical director and president of the Pacific Inpatient Group (PIMG), the hospitalist group that provides inpatient coverage at all four of our campuses. He has also served as treasurer of the CPMC medical staff.

Congratulations to Dr. Giang on his new role.

CPMC is proud to announce that Dr. Dobri Kiprov, chief of Immunotherapy in the Department of Medicine, was recently chosen by the American Society for Apheresis (ASFA) to receive the annual Francis S. Morrison, MD, Memorial Award and Lecture. Dr. Kiprov presented his keynote lecture, “The Plausible Future of Therapeutic Plasma Exchange,” on May 23, 2013, at ASFA’s annual meeting in Denver, Colorado. ASFA’s memorial lectureship award program recognizes individuals who have made major contributions to the field of apheresis medicine and apheresis professionals who have made a lasting difference in the field at the national level.

The San Francisco Board of Supervisors voted unanimously to give final approval of CPMC’s plan to rebuild CPMC, and Mayor Ed Lee has signed the legislation. We can now plan to demolish the Cathedral Hill Hotel and build a new 300-bed general acute care hospital on the site at Van Ness Avenue. There will also be a new 120-bed acute care hospital built on the St. Luke’s site, which should open a few years after the Cathedral Hill building.

Health care reform, information technology, advances in medical knowledge, and the looming shortage of physicians bring massive change for physicians. We need physicians who are prepared to navigate change, lead teams, lead medical groups and organizations, and lead health care delivery systems—all while providing, and assuring that the delivery system as a whole provides, excellent patient care. Sutter Pacific Medical Foundation (SPMF) sponsors physicians in career development and leadership training at all levels. Dr. Jordan Horowitz, our medical director for quality, notes that as with the practice of medicine, there are basic leadership skills to be mastered. “Until I participated in leadership training, I didn’t know that learning how to run meetings effectively was just as learnable a skill as being taught how to perform a C-section.”

We offer leadership training for frontline clinicians, physicians who have taken on leadership positions, established leaders, and executive leaders. We rely on these physician leaders in many roles. Physician champions serve as experts and advocates for specific projects such as our electronic health record. Division chiefs oversee a clinical service line such as primary care or endocrinology. Physician site leads work with administrative dyad partners to ensure optimal operational performance.

Medical directors have overall responsibility for ongoing activities such as quality control. SPMF recently sent a group of physicians to Sutter Health’s Physicians’ LeaderLab, advanced training for established physician leaders. Dr. Bob Napoles, our division chief for primary care, said, “I was able to obtain critical information about myself through the Myers-Briggs personality assessment and a 360 feedback from colleagues, peers, and staff. This highlighted my strengths and weaknesses and helped me create a personal leadership strategic plan.” Physician leadership is paramount. As Dr. Horowitz commented, “Physicians are our most valuable asset. Their professional development is key to the organization’s success.”

September 2013 San Francisco Medicine

29

IN MEMORIAM Nancy Thomson, MD Frank S. Yang, MD Dr. Frank S. Yang was born in Shanghai on December 15, 1944, and grew up in Hong Kong. He left China to attend Stanford University, followed by medical training at UCSF, which he completed in 1972. In his private practice of internal medicine and gastroenterology, he was affiliated with CPMC, Chinese, French, St. Francis, and St. Luke’s hospitals.

His knowledge, generosity, and playfulness will be missed.

He is survived by his wife, Anna; his daughters Cynthia and Christina; and seven siblings who live in Hong Kong, Hawaii, and North Carolina. A memorial service was planned for Sunday, June 23, at the Chinese Cultural Center.

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John Callander

Dr. John Callander was born in 1923 in San Francisco, the son and grandson of physicians. He died June 9, 2013, a few days short of his ninetieth birthday. He is survived by his wife of sixty-four years, Barbara: his sister; six children; sixteen grandchildren; and two great-granddaughters.

Friends and family remember him as a community activist and top-notch physician who frequently put family and community first. His daughter, Sara Stephens, a Bay Area nurse, said, “He felt strongly that the community was something you gave back to and made better.”

He attended Johns Hopkins Medical School and did residencies at Western Reserve Care System, Feather River Hospital in Paradise, and UCSF. Being somewhat deaf, he was told he couldn’t learn diagnosis without a stethoscope. A mentor, hard of hearing herself, taught him to diagnose by feeling vibrations instead. That experience inspired him to take many young doctors and students under his wing. His son, Peter, who graduated from St. Louis University in 1995, was in practice with him.

“He set an example that most doctors can’t live up to,” said Dr. Frederic Bost, a mentor and partner at California Pacific Orthopedic and Sports Medicine, which Dr. Callander founded in 1972. His list of charitable efforts, as lengthy as it was varied, included volunteering with the San Francisco Free Clinic, where he cared for patients, and the San Francisco Ballet, where he tended to dancers.

He never left a conversation without saying, “What can I do to help you?” recalled Rob Conolly, president of the Boys and Girls Clubs of San Francisco, where Dr. Callander was a board member for fifty years. “It was just part of his character.”

He often scheduled surgeries late at night as a younger man, to make sure he was home for dinner with his wife and six young children. When he made hospital rounds, his children were often in tow.

30

San Francisco Medicine September 2013

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