An early innovator in the national hospitalist movement, Kaiser San Francisco remains at the forefront of academic hospitalist training. Our inpatient experience provides exposure to a diverse, largely urban patient population with complex medical conditions who are often referred from other hospitals in the Kaiser system to receive specialty care. Following the Affordable Care Act, we have seen a dramatic increase in the number of patients who previously lacked health insurance and often have multiple complex medical conditions. Under the guidance of experienced hospitalist faculty, resident physicians practice patient-centered, evidence-based care within an integrated multidisciplinary health care system. Recently we have developed a robust curriculum in point of care ultrasound and procedural medicine.
We recognize the importance of point-of-care ultrasound (POCUS) to enhance clinical care. All inpatient teaching services have access to dedicated portable ultrasound machines. Moreover, we are fortunate to have two faculty members who are experts in POCUS and are instructors at the national ACP and SHM conference pre-courses. They have spearheaded the implementation of a year-long curriculum that includes formal lectures, standardized patients, image review, and integration into Morning Report and Journal Club. Our long-term goal is to prepare our residents to earn the SHM/Chest Point-of-Care-Ultrasound Certificate of Completion.
We have a unique model of inpatient ward medicine that separates Admitting and Rounding roles into two distinct rotations. This change was implemented in response to resident feedback and has significantly improved the educational experience in each setting. Notably, the change eliminated the previous short/long call system and replaced it with a round robin system of assigning new patients. The elimination of “boluses” of admissions in favor of a “drip system” has contributed to a more manageable daily workload and, as a result, an improved learning experience and work/life balance.
Admitting teams are based in the Emergency Department and work closely with the attending hospitalist to evaluate patients at the time of their initial presentation. The Admitting team stabilizes, diagnoses and admits patients for further care, and in doing so, hones their skills at clinical reasoning, differential diagnosis, and triage. Rounding teams are based on the wards and are not responsible for admitting patients from the Emergency Department. Because of this, the Rounding team is able to focus their attention on their hospitalized patients and have time for teaching rounds, patient care, questions from nurses, family meetings, etc.
- There are two Admitting teams, each comprised of one resident, one intern, and one supervising hospitalist.
- Admitting teams admit patients every other day; on non-admitting days, the Admitting resident is on the Procedure service, while the Admitting intern performs cross-cover duties.
- The Procedure service resident is available to perform procedures such as thoracentesis, paracentesis, lumbar puncture, and arthrocentesis on hospitalized patients and learns to use bedside ultrasound for procedural guidance.
- On the Admitting rotation, each resident and intern has three days off in a two-week block.
- Three Rounding teams have the traditional structure of a hospitalist attending, one resident, two interns, and often a visiting fourth-year medical student or a third-year medical student from UCSF. These teams have a cap of 14 patients.
- A fourth Rounding team is comprised of one hospitalist and one senior resident. This team has a cap of 12 patients.
- There is no long, short, or overnight call.
- The night float intern covers all cross-cover duties after hours.
- All residents and interns have one day off per week
- The ICU team consists of three interns, one night-float intern, one junior medical resident, one daytime senior medical resident, one nighttime senior medical resident, and critical care and cardiology fellows and attendings.
- Critical care and cardiology fellows and attendings are available 24/7 to provide excellent back up support and supervision to the residents.
- There is no overnight call.
- All residents and interns have two days off per two-week block
- One ER night float resident works with the on-call hospitalist attending to admit patients overnight.
- One night float intern provides cross-cover for ward patients on teaching services.
- One ICU nighttime senior resident and one night-float intern admit and provide cross-cover care, respectively, for ICU patients.
- We offer several inpatient elective experiences for residents interested in careers in hospital medicine or critical care medicine.
- Procedure Rotation: As part of the Admitting rotation, residents perform various procedures, including central line placements, lumbar punctures, paracenteses, and thoracenteses under attending supervision and guidance.
- Hospitalist Rotation: This experience is set in the fourth Rounding team made up of one resident and one hospitalist attending. It provides valuable experience in independent hospitalist practice and an opportunity to practice with greater autonomy.
- Cardiovascular ICU Elective: As one of the busiest and most highly regarded hospitals in the nation for cardiac care and heart surgery, the Cardiovascular ICU (CVICU) at Kaiser San Francisco provides a unique opportunity for residents to participate in the care of cardiac surgery patients, including transcatheter aortic valve replacement (TAVR) and Mitraclip transcatheter mitral valve repair patients. In this rotation, the resident is exposed to a wide range of acute postoperative, rhythm, hemodynamic and respiratory issues.
- Perioperative Medicine (POM) Elective: Residents work with a hospitalist to assess surgical risk and optimize patients for planned surgery, and also assist in the care of postoperative patients on the wards.
- Patient Safety Elective: Kaiser San Francisco has a Patient Safety Fellow involved in patient safety initiatives, performance improvement projects, peer review and root cause analyses. Residents gain experience in hospital operations and quality improvement.
Ambulatory Care Medicine
We have a long-standing tradition of excellent training in outpatient medicine. Ours is a busy practice in an urban setting with a diverse patient population that includes patients covered through traditional Kaiser health insurance, Medicare, Medi-Cal and Healthy San Francisco, an innovative program designed to make health care services accessible and affordable to uninsured San Francisco residents.
Kaiser San Francisco handles approximately 300,000 ambulatory visits each year to the Department of Adult and Family Medicine. We have two main campuses for ambulatory care – the San Francisco Medical Center and Medical Offices and the San Francisco Mission Bay Medical Offices that opened in March 2016.
- Residents are assigned a primary clinic site at one of the two San Francisco campuses and see patients in a dedicated resident clinic staffed by a core group of preceptor faculty.
- Each resident clinic is supported by a complement of allied health workers, including medical assistants, diabetes nurses, clinical health educators, behavioral medicine therapists, and physical therapists.
- During inpatient ward rotations, residents have one full-day continuity clinic every other week. On these clinic days, the resident is free of any inpatient responsibilities. There is no continuity clinic during ICU, Night Float, or Admitting rotations. Conversely, during outpatient/elective blocks, residents have concentrated continuity clinic time, allowing for a more robust longitudinal ambulatory experience.
- Residents grow and manage their own panel of patients over the course of their residency.
- In addition to working with a group of dedicated core ambulatory faculty, there are various specialists available on site for consultation, including the innovative roving dermatologists and cardiologists, who provide “on-demand” in-person consultation.
- One four-week block during each year of residency training. There are 2-3 days of continuity clinic per week as well as other experiences, including geriatrics (skilled nursing facility, community home visits, hospice/palliative care), dermatology, sports medicine, musculoskeletal clinic, and underserved clinic experience.
- Residents with an interest in primary care can also pursue an additional two-week block of advanced ambulatory training.
To complement our varied clinical experiences, our program emphasizes exposure to a broad array of clinical topics and scenarios through daily teaching conferences that allow residents to acquire the skills and knowledge needed to become an expert internist. Teaching occurs in various forms, ranging from formal didactic rounds to pearls of the physical exam taught at the bedside during rounds. We use a multidisciplinary approach to patient care in all settings with an emphasis on evidence-based medicine.
- Morning Report: 8:00 a.m. – 9:00 a.m. This conference is perhaps the most valuable educational venue for our residents, and thus we have ensured protected time from clinical duties to allow our residents to attend. Interesting and often undifferentiated cases, from both the inpatient and outpatient setting, are presented. Case-based discussions are moderated by our chief residents and emphasize diagnostic reasoning, differential diagnosis, the use of problem representations, and the use of illness scripts. There is a special intern-only Morning Report on Mondays during which the ward residents cover their clinical responsibilities.
- Noon Conference: 12:30 – 1:30 p.m. Residents and faculty mingle at this daily teaching conference. Speakers from our own faculty or guest speakers from outside our institution give lectures on a variety of current topics in internal medicine. Included in these series are regular Morbidity and Mortality, Complications, Interdepartmental Grand Rounds, Tumor Board, EKG Review, Medical Jeopardy, Board Exam Review, and Journal Club. Every other month, there are Peer Review, Patient Safety & Quality Improvement, and Resident Research conferences.
- Intern Report: 1:30-2:30 p.m. weekly on Wednesdays. Interns are excused from clinical duties to attend this one-hour session that emphasizes essential intern-level skills and topics. The format varies including “chalk talks”, literature reviews, and interactive case presentations.
- Ward Attending Team Rounds: This clinically oriented, small-group teaching session is based on patient cases from the inpatient teams. Team rounds may occur at the end of work rounds each morning or during the afternoon team meeting and are typically conducted by the hospitalist attending.
- Cardiology and Intensive Care Rounds: These are conducted each morning with the ICU/CCU team by the attending cardiologist and intensivist, and typically begin with a “Ten Minute Didactic” where current topics in ICU medicine are covered systematically. Residents also receive simulation training, including ultrasound guided central line insertion on a mannequin.
- Subspecialty Rounds: Residents on subspecialty electives attend these teaching and consultation rounds, which are conducted several times per week. Our residents benefit from working one on one with subspecialists and the focused attention on a particular area of internal medicine.
- Academic Half-Day Seminar: Tuesdays from 10:30 a.m. – 1:30 p.m. A resounding success since its inception in 2005, the Academic Half Day Seminar is a three-hour block of protected time free from clinical duties where residents can focus on learning in a small group environment.
Typical Yearlong Schedule
|Rotation||PGY-1 Categorical||PGY-1 Preliminary||PGY-2||PGY-3|
|Rounding Teams||14-16 weeks||16 weeks||8-10 weeks||8-10 weeks|
|Admitting Teams||4-6 weeks||6 weeks||4-6 weeks||4-6 weeks|
|ICU/CCU||6-8weeks||8 weeks||8 weeks||8 weeks|
|Night Float||4-6 weeks||6 weeks||2-4 weeks||–|
|Emergency Medicine||2 weeks||2-4 weeks||2 weeks||–|
|Ambulatory Care Block||4 weeks||–||4 weeks||4 weeks|
|Elective Rotations||10 weeks||8-10 weeks||8-12 weeks||12-16 weeks|
|Vacation||3 weeks +5 days educational leave||3 weeks +5 days educational leave||4 weeks +5 days educational leave||4 weeks +5 days educational leave|