An early adaptor in the hospitalist movement, Kaiser Permanente San Francisco remains a leader in academic hospitalist training. Our inpatient experience provides exposure to a diverse, urban patient population with complex medical conditions, as well as patients referred for specialty care from other hospitals in the Kaiser Permanente Northern California system. Following the implementation of the Affordable Care Act, we have seen a dramatic increase in the number of our patients who previously lacked health insurance and often have multiple complex medical conditions. Under the guidance of experienced hospitalist faculty, our residents practice patient-centered, evidence-based care within an integrated multidisciplinary health care team.
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 distributing newly admitted patients. The elimination of “boluses” of admissions in favor of a “drip system” has contributed to a more predictable workday, an improved learning experience, and better work/life balance. For those interested in hospital medicine, this also prepares them for a model often seen in hospitalist practices.
Admitting teams, comprised one resident and one intern, work closely with the attending hospitalist in the Emergency Department to evaluate patients at the time of their initial presentation. The Admitting team diagnoses, treats, and admits patients, 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, they can better focus their attention on their hospitalized patients and experience fewer interruptions to teaching rounds and patient care activities. Rounding teams take over the care of newly admitted patients only after they have been admitted to the hospital and the rounding team has received a thorough hand-off from the admitting team.
- Admitting teams are comprised of one resident, one intern, and one supervising hospitalist.
- During this rotation, admitting teams have a mix of admitting and non-admitting days. On non-admitting days, the Admitting resident is on the Procedure service, while the Admitting intern does cross-cover for the ward teams.
- On non-admitting days, the Procedure service resident performs a variety of procedures, including thoracentesis, paracentesis, and lumbar puncture, and learns to use bedside ultrasound for procedural guidance.
- Three Rounding teams have the traditional structure of a hospitalist attending, one resident, two interns, and often, a medical student. These teams have a cap of 14 patients.
- A fourth Rounding team is comprised of one hospitalist and one senior resident, simulating a “hospitalist rotation”, and 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 in seven free of clinical work and required education.
- The ICU team consists of three interns, two residents, a cardiology fellow, and critical care and cardiology attendings.
- There is an intensivist in-house at all times to provide back-up support and supervision to the residents. There is also cardiology fellow and attending back-up.
- There is no overnight call. There is a night float team consisting of one intern and one resident.
- All residents and interns have two days free of clinical work and required education per two-week block.
- The night float resident works with the on-call hospitalist attending to admit patients overnight from the Emergency Department.
- The night wards intern provides cross-cover for ward patients on teaching services.
- The night ICU senior resident and night ICU intern admit and provide cross-cover care for ICU patients.
We recognize the importance of point-of-care ultrasound (POCUS) to enhance clinical care. All inpatient teaching teams have their own dedicated portable ultrasound devices. Moreover, we are fortunate to have faculty members who are POCUS experts and regularly teach at the national ACP and SHM conference pre-courses.
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.
- Residents are assigned a primary clinic site at one of the two Kaiser Permanente San Francisco campuses and see patients in a dedicated resident clinic staffed by a core group of faculty preceptors.
- Each resident clinic is supported by a dedicated medical assistant, as well as other allied health workers, including diabetes nurses, clinical health educators, behavioral medicine therapists, and physical therapists.
- Residents have a schedule that regularly alternates four-week inpatient and outpatient blocks (A/B schedule). Continuity clinic occurs only during their outpatient ambulatory and elective rotations. A balance of inpatient and outpatient blocks allows for regular intervals of continuity clinic throughout the year.
- Residents are expected to 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 “on-demand” in-person consultation, including the innovative roving dermatologists, cardiologists, orthopedists, proceduralists, and behavioral medicine therapists.
- Third-year residents rotate at community clinics such as the Clinic by the Bay, a community primary care clinic for uninsured, underserved patients.
- During dedicated Ambulatory Care rotations, residents also have opportunities for other experiences in addition to continuity clinic such as geriatrics, hospice/palliative care, dermatology, sports medicine, and musculoskeletal clinic.
- We offer elective rotations in all the traditional internal medicine subspecialties, including cardiology, endocrinology, geriatrics, gastroenterology, hematology/oncology, infectious diseases, nephrology, neurology, pulmonology, and rheumatology.
- There are also many other elective options, including allergy, anesthesia, addiction medicine, Cardiovascular ICU, dermatology, ENT, HIV/transgender medicine, Injury Center, occupational medicine, ophthalmology, palliative care, perioperative medicine, psychiatry, sports medicine, and women’s health.
- Residents interested in working with underserved populations around the world and learning about the health effects of poverty, migration, climate change, emerging infectious diseases, and access to healthcare are encouraged to consider the Kaiser Permanente Global Health Program.
To complement our varied clinical experiences, our program provides exposure to a broad array of topics and curriculum, including clinical and evidence-based medicine, Diversity, Equity and Inclusion, Quality Improvement and Patient Safety, and Wellness. Teaching occurs in various forms, ranging from formal didactics to informal chalk talks to clinical reasoning discussions on rounds to pearls of the physical exam taught at the bedside.
- Morning Report: 8:00-8:45 a.m. This mandatory conference is perhaps the most valuable educational venue for our residents. Interesting and often undifferentiated cases from inpatient and outpatient settings are presented. Case-based discussions are moderated by our chief residents with contributions from faculty discussants, and emphasize diagnostic reasoning, differential diagnosis, and the use of problem representations and illness scripts.
- 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, clinical problem-solving cases, Interdepartmental Grand Rounds, EKG Review, Medical Jeopardy, Board Exam Review, and Journal Club conferences. Senior residents present at least one conference and lead one Journal Club session each year.
- Intern Report: 1:45-2:30 p.m. on Mondays. 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.
- Academic Half-Day Seminar: Tuesdays from 10:30 a.m. – 1:30 p.m. Since 2005, we have held a weekly Academic Half Day Seminar, 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||14-16 weeks||8-10 weeks||10 weeks|
|Admitting Teams||6 weeks||4-6 weeks||4-6 weeks||6-8 weeks|
|ICU/CCU||6-8 weeks||6-8 weeks||8 weeks||8 weeks|
|Night Float||6-8 weeks||6-8 weeks||2-4 weeks||–|
|Emergency Medicine||2 weeks||2-4 weeks||2 weeks||–|
|Ambulatory Care Block||Ambulatory Continuity Clinic throughout the year||–||6 weeks||6 weeks|
|Elective Rotations||14-16 weeks||14-16 weeks||18-20 weeks||20-22 weeks|
|Vacation/Educational Leave||3 weeks +5 days educational leave||3 weeks +5 days educational leave||4 weeks +5 days educational leave||4 weeks +5 days educational leave|