ZSFG Primary Care Track: Program Overview

SFPC is a three-year program leading to board eligibility in Internal Medicine. It is based at ZSFG and its affiliated San Francisco Health Network—a community of top-rated primary care health centers that serves all residents of San Francisco. Residents of SFPC are fully integrated into the UCSF Internal Medicine Residency and rotate through the other teaching hospitals, including UCSF Moffitt/Long Hospitals and the San Francisco VA Medical Center.

 

SFPC Program: Education

R1 (Intern) Year: The intern year for primary care medicine interns is similar to that for the categorical internal medicine interns, with 9-10 months spent on hospital-based and emergency department rotations and 2-3 months on outpatient rotations. All SFPC interns begin their continuity clinic during their intern year, at the Richard H. Fine People’s Clinic—an adult medicine clinic at ZSFG. During the first outpatient month, SFPC interns receive an intensive clinical immersion curriculum designed to develop and enhance clinical skills and increase the efficiency and comfort level of working in a busy clinic with patients with complicated diseases. During subsequent ambulatory months, residents are introduced to the curricular themes Community Medicine and Health Care Systems, complete with site visits to organizations and institutions that demonstrate best practices in the treatment and care of marginalized and vulnerable patient populations. All SFPC interns have their ambulatory months together, which provides an opportunity for community building, mentoring and other shared learning and morale-building experiences. Resident- and faculty-led support groups and resident retreats are held during outpatient months.

Sample of week during ambulatory rotation for an Intern

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

AM

Urgent Care at the VA

 

AM

SFPC R1 Core Didactics

AM

Intern Half-Day (4-hour didactics on core medicine topics)

AM

Site Visit to Treatment Access Program and Medical Respite

AM

SFPC R1 Core Didactics

PM

Street Outreach Services – Homeless Van

 

PM

Continuity Clinic at RFPC

PM

Personal Half-Day

PM

Continuity Clinic at RFPC

PM

Continuity Clinic at RFPC

 

R2 and R3 Years: 2nd-and 3rd-year SFPC residents spend six to seven months of the year on ambulatory rotations and the remaining five to six on inpatient rotations. Ambulatory months are designed to include intensive primary care experiences with rotations through core medicine subspecialty clinics and didactics curricula in ambulatory, behavioral and social medicine, in addition to regular continuity clinic. Residents also complete research, community, educational and/or quality improvement projects during this time.

Sample of week during an ambulatory month for an R2

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

AM

Community-based Continuity Clinic

 

AM

Admin Time

AM

Specialty Clinic 2 - Rheumatology

AM

SFPC R2/R3 Core Didactics

AM

Health Equities (Social Medicine) Didactics

PM

Specialty Clinic 1 – Infectious Disease

 

PM

12:45-1:15: Pre-clinic Conference

PM & Evening: Continuity Clinic at RFPC

PM

Specialty Clinic 3 - Dermatology

PM

12-1: Journal Club

1-5: Continuity Clinic at RFPC

PM

12-1: Primary Care Grand Rounds

1-5: R2/R3 Core Didactics at Mt. Zion

Sample of week during an ambulatory month for an R3

MONDAY

TUESDAY

WEDNESDAY

THURSDAY

FRIDAY

AM (8:15 am – 2:30 pm)

Elective Clinic – Prison Medicine at San Quentin Medical Center

 

AM

Specialty Clinic 1 - Endocrinology

AM

Elective Clinic – City STD

AM

SFPC R2/R3 Core Didactics

AM

Health Equities (Social Medicine) Didactics

PM (8:15 am – 2:30 pm)

Elective Clinic – Prison Medicine at San Quentin Medical Center

 

PM

12:45-1:15: Pre-clinic Conference

PM & Evening: Continuity Clinic at RFPC

PM

Project Time - QI

PM

12-1: Journal Club

1-5: Continuity Clinic at RFPC

PM

12-1: Ambulatory M&M

1-5: R2/R3 Core Didactics at Mt. Zion

 

Continuity and Core Clinics
During the ambulatory months, residents have three half days of continuity clinic per week in the Richard H. Fine People’s Clinic (RFPC) at ZSFG. Most patients have multiple chronic illnesses and nearly all have complicated medical and social needs. RFPC patients come from diverse backgrounds, and roughly half do not speak English as their first language. With the passage of the Affordable Care Act, the majority of patients are enrolled in some form of government-subsidized health insurance.

 

In addition, second- and third-year residents select a second continuity clinic site at a community-based primary care clinic that exposes them to different populations of patients and systems of care. The selection of the site for a resident’s second continuity clinic is based on a number of factors, including the resident’s career and/or research interests, and clinic’s staffing needs. Examples of current second clinic sites include Southeast Health Center (safety net clinic in the Bayview), ZSFG Ward 86 (HIV care), and Tom Waddell Urban Health Center (safety net clinic in the Tenderloin). Residents also rotate through specialty clinics including orthopedics, women’s health, dermatology, pain medicine, addiction medicine and psychiatry—among others. Residents' schedules provide protected time, allowing them to develop areas of particular clinical expertise, conduct clinical services projects, and perform research on the care of vulnerable patients.

 

Social Medicine
The Social Medicine curriculum, known as the HEAAT (Health Equities Advocacy & Academic Training) track, is based at ZSFG and is focused on examining the socio-economic and political factors that produce disparities in health and healthcare and impact the practice of medicine. Through a series of themed lectures, workshops and site visits, residents acquire in-depth knowledge of the issues surrounding these disparities, with specific concentration on the care of vulnerable patients both within the context of the doctor-patient relationship and entire healthcare delivery systems. By default, SFPC residents are enrolled in the HEAAT track of the larger Health & Society Pathway/Area of Distinction (AoD). The track is a two-year curriculum starting the second year of residency and spans the R2 and R3 years. The content is delivered every Friday morning during ambulatory months, with themes that include housing & homelessness, diversity, cultural awareness & inclusion, substance use disorders and chronic pain, incarceration medicine, and physician advocacy. Curricular content draws upon the textbook “The Medical Management of Vulnerable and Underserved Patients: Principles, Practice and Populations,” most of which are authored by DGIM faculty at ZSFG. Residents participate in site visits and engage with community leaders, advocates and policy experts. The advocacy training component includes teaching on narrative (“Writing for Change”) and traditional legislative and administrative advocacy, complemented with a visit to Sacramento to engage state congresspersons and senators about legislation that impacts our patients.

 

Another unique aspect of our social medicine curriculum is the opportunity to collaborate with residents of other ZSFG-based primary care and specialty training programs—Family and Community Medicine, Emergency Medicine, Neurology, Nurse Midwifery, Pediatrics, Ob-gyn, and Psychiatry—dedicated to the care of vulnerable populations through a certificate program called STEP UP (ZSFG Training and Education Programs for Underserved Populations). STEP UP is an interdisciplinary and cross-departmental project that aims to align the different specialties to improve the learning experience in social medicine. A few of the program’s learning activities include:

  • Multidisciplinary Grand Rounds on Investing in Community to Address Social Determinants of Health
  • Joint learning session that includes a site visit to Marea Alta Family Housing, an innovative mixed-use, transit-oriented, affordable housing development in San Leandro at the BART (Bay Area Rapid Transit) station
  • Joint learning session on Immigration Law with legal experts from the East Bay Community Law Center
  • Multidisciplinary Grand Rounds and Panel Discussion on Challenging Islamophobia
  • Advocacy Action Night – Storytelling and Op-Ed Workshop that teaches health advocacy skills like writing letters or other opinion pieces, drafting position statements, or organizing others around a specific issue related to health and healthcare access.

 

Innovations in Primary Care and Quality Improvement
Recognizing the challenges of providing primary care in a safety net environment, our faculty, in collaboration with other members of the healthcare team, have developed a didactics curriculum for residents that specifically teaches them a structured approach to improving healthcare delivery in the ambulatory setting. There is a core Quality Improvement and Patient Safety & Leadership (QIPSL) curriculum, which is intertwined with our Building Blocks curriculum about Primary Care Transformation.

Each resident will complete a quality improvement project during residency. Often these projects are very impactful for care delivery in RFPC. Residents are also invited to join our clinic’s management team to hone skills in practice transformation. It is crucial that our residents graduate with an understanding of how to be change agents within primary care.

Scholarly Projects
All residents will participate in scholarly work. Our residents have a diversity of interests including community engagement and program development, medical education, health care systems innovation, and traditional academic research. We support our residents to pursue and work in areas in which they find inspiration. Our goal is to pair residents with mentors who are invested in their success and will help them accomplish their goals. Scholarly work often culminates in peer-reviewed presentations at the annual Society of General Internal Medicine (SGIM) conference, which our residents and DGIM faculty attend.

Conferences/Journal Clubs
The sample schedules presented earlier show the types of conferences residents typically attend during their ambulatory rotations. Residents also have the opportunity to attend local Continuing Medical Education (CME) conferences related to primary care taught by UCSF faculty, such as Medical Management of HIV/AIDS and HCV, Primary Care Medicine – Principles and Practice and Controversies in Women’s Health.

Primary Care Grand Rounds, sponsored jointly by the ZSFG-based Division of General Internal Medicine and the Department of Family Medicine, occur monthly and feature talks on ambulatory care medicine, social justice and medicine, public health, etc. STEP UP Multidisciplinary Grand Rounds are incorporated into the grand rounds schedule.

Residents are assigned to lead one Journal Club presentation each year. They are paired with a DGIM faculty member who will work with them to analyze the evidence-based literature and formulate questions for discussion. Journal Club is well-attended with residents, faculty, and, sometimes, invited faculty from other divisions or departments. Twice a year, joint journal clubs are held with the other tracks of the residency—UCPC in the fall and PRIME in the spring.

Retreats/Mentors/Support
Program leadership and division faculty provide strong mentorship to support residents in their professional development and career choices. Semi-annual retreats (one evening and one weekend) are held for the residents and faculty to build community and to discuss program issues in a more relaxed environment. There are also monthly support groups facilitated by one of our alumni, as well as monthly social get-togethers to promote team-building and well-being.

Global Health Program
In response to the high level of resident interest in international training opportunities, UCSF has developed a Global Health Program. Third-year residents may use one elective month to complete the Global Health Program Rotation. Residents receive support to rotate in one of the international sites. Rotations are currently located in New Mexico (Indian Health Service), Uganda, Kenya, Saipan, Tanzania, Mexico and China.