An early adopter 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 were previously uninsured 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 the model most often seen in hospitalist practice.
Admitting teams, comprised of one resident and one intern, work closely with the attending hospitalist to evaluate patients at the time of their initial presentation in the Emergency Department. The Admitting team diagnoses, treats, and admits patients, and in doing so, hones their skills in clinical reasoning, differential diagnosis, and triage.
Rounding teams are based on the wards and are not responsible for admitting patients from the Emergency Department. This allows them to focus on their hospitalized patients with fewer interruptions to teaching rounds and patient care activities. Rounding teams take over the care of newly admitted patients 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 spends time in ambulatory clinic or is on cross-cover duty for the ward teams.
- The Procedure service resident performs a variety of procedures under supervision – central line placement, thoracentesis, paracentesis, and lumbar puncture, including the use of point-of-care 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 always an intensivist in-house 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 admitting resident works with the on-call hospitalist attending to admit patients overnight through the Emergency Department.
- There are 2 night float interns – one provides cross-coverage for ward patients and the other 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 medical assistant, chronic condition nurses and case managers, pharmacists, clinical health educators, behavioral medicine therapists, and social workers.
- Continuity clinic occurs regularly throughout the year to enable our residents to grow and manage their panel of patients.
- In addition to in-person visits, residents learn how to manage their patients via all modalities of telehealth (telephone, video visits, and electronic communication). There is a coverage system in place for managing messages when residents are unavailable in clinic.
- Immediate phone consultative services from subspecialists are also available to facilitate optimal and timely care of clinic patients.
- Third-year residents rotate at community clinics such as the Clinic by the Bay, a community primary care clinic for uninsured, underserved patients. Opportunities also exist for rotations at other Department of Public Health clinics in San Francisco.
- We offer elective rotations in all the traditional internal medicine subspecialties, including cardiology, endocrinology, geriatrics, gastroenterology, hematology/oncology, infectious diseases, nephrology, neurology, palliative care, 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, 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, Equity, Inclusion, and Diversity, Quality Improvement and Patient Safety, Lifestyle Medicine, 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. 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. This conference is always highly rated by our residents.
- Noon Conference: 12:30-1:30 p.m. At this daily teaching conference, speakers from our own faculty or 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. once weekly. 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||4 weeks||–|
|Emergency Medicine||2 weeks||2 weeks||2 weeks||–|
|Ambulatory Care Block (in addition to Continuity Clinic throughout the year)||2 weeks||–||4 weeks||6 weeks|
|Elective Rotations||6 weeks||6 weeks||14-16 weeks||16-18 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|