Rebecca Shunk, MD
Director, Center of Excellence in Primary Care Education,
Associate Program Director, PRIME Program, UCSF Internal Medicine Residency
What was your career path to UCSF and our VA campus?
I grew up in rural South Carolina, (think one stoplight) went to medical school at the Medical University of South Carolina and really never thought of leaving that wonderful state until I met my husband. He had a broader plan that has truly enriched my life. This plan included residency at the University of Chicago. I completed my internal medicine residency at both the University of Chicago and the Johns Hopkins Bayview Internal Medicine Residency. I moved to Johns Hopkins Bayview as a PGY-3 to be with my husband who had accepted a Cardiology Fellowship at Hopkins. Believe it or not the combination of two residencies really served me well as my time at Bayview provided the bread and butter medicine that University of Chicago did not provide at the time. I stayed on as a Chief Resident at Bayview and then as the Associate Program Director and Director of a fledgling Hospitalist program. In the summer of 2000 when my husband Rick Shunk (a UCSF Faculty member and interventional cardiologist) finished his fellowship we started to look at academics jobs. UCSF and the San Francisco VA were a great fit for both of us. The “follow your passion and we will support you” attitude really appealed to me. I was also very excited about the opportunity to work with UCSF residents.
How did you first become engaged in Quality and Safety improvement work?
Like most everything I have done in my career I became engaged in quality and safety work when I realized I had a lot to learn. When I trained as a resident there was very little training in Quality and Safety in residency programs. Typically select hospital staff, usually with a masters in public health, worked on quality and safety, kept to themselves and did not engage others in the work. As I worked as both a hospitalist at Bayview and as a primary care provider at the SFVA, I encountered medical errors or systems issues that really needed to change but I personally did not have a paradigm to help make those changes. At the same time I was completing my American Board of Internal (ABIM) Recertification requirements and completed my first PDSA cycle using the Practice Improvement Modules (PIMS). This was about the same time as our internal medicine residency program began thinking of how to expand quality and safety improvement work beyond the inpatient setting to include the ambulatory setting. Having a personal need for education in this area, I led the charge to apply for and ultimately received an ABIM Quality Improvement Grant allowing us to have all of our residents complete the online PIMS. This led to a great deal of learning that continues today on quality improvement and safety.
What’s been your secret to success in marrying the activities with educational ones around QI and safety in the VA ambulatory setting?
If I had to sum it up in one word our secret to success has been focusing on being practical. Being practical means finding a project meaningful to both trainees and our clinic leaders in Medical Practice. Getting this buy-in requires keeping the projects clinically relevant to both the administrators of the clinic and our resident trainees (and now interprofessional trainees). In the beginning residents felt like they did not have the time to work on a big clinical project. We educated the trainees on the practicality of SMART aim statements. In other words, they did not have to choose large time consuming projects that changed the entire structure of the clinic. Trainees learned small but manageable (practical) cycles of change can be powerful as well. Working with the clinic leadership to let them know it was no longer practical to exclude trainees in certain quality and safety initiatives (given the large number of patients they care for) also helped to marry the two missions of education and quality and safety activities in the clinic.
What do you think are the most effective strategies to engage, teach, and mentor trainees in QI and safety activities?
Our chosen QI and safety activities are quality improvement projects. These projects allow trainees to really see all of the key components of Quality. Our teaching is in the context of these projects. The VA, especially, allows our residents to examine the system in which they work as well as the data in their own patient panel including patient satisfaction and clinical outcomes. These projects allow them to learn more about their panels as well as see the results of their quality improvement efforts. Trainees become more invested in their clinic environment and empowered to make change as well as become more satisfied with their ambulatory care experience. QI projects help trainees realize that no matter whether they ultimately practice as a subspecialist based in a hospital or as a solo primary care provider, they can improve the quality and safety of their clinical settings. We have found as we have mentored trainees through QI and safety projects that the trainees who really take on a lead role in the projects are the ones who learn the most. If too many trainees participate on one project - they have less meaningful work to do, are less engaged and learn less. We also make sure trainees chose a project in which they have a strong personal interest to ensure they have the desire to see the project through to the end.
You were recently been appointed as the Director of the SFVA newly established Center of Excellence in Primary Care Education. Tell us a little bit about the Center and the concept of Education in Patient Aligned Care Teams (EdPACT).
The VA is transforming its primary care delivery system to improve coordination and continuity of care through patient-aligned care teams (PACTs). As part of this transformation the VA’s Office of Academic Affiliations has designated 5 Centers of Excellence (COE) in Primary Care Education to develop new educational models for residents and nurse practitioner (NP) students. The SFVA was awarded a COE, EdPACT, which is a collaborative effort with the UCSF Schools of Medicine and Nursing. Our interprofessional EdPACT faculty team has developed a team-based, interprofessional model of ambulatory care education that prepares residents and NP students to engage in patient-centered approaches to care and work collaboratively with a variety of health professionals to create comprehensive and coordinated care plans for patients. In July 2011, teams comprised of two internal medicine residents, 1 NP student, an RN, LVN and clerk began working together to deliver care to a shared panel of patients. A resident and NP student primary clinic day begins with a huddle that includes the resident, NP student, RN, LVN and clerk. The RN has reviewed the patients for the next 2 weeks and presents them to the trainee team; the LVN has called all of the current day’s patients and elicited their agendas; and the clerk is present to help with rearranging patients deemed appropriate to put into the trainees’ telephone clinic. After seeing several patients, the trainees have time for panel management where the trainees have their telephone clinic, review their patient database for clinical outliers or prepare for upcoming interprofessional case conferences. There is an extensive curriculum based on principles of workplace learning addressing teamwork skills; patient-centered communication techniques; performance improvement and other patient-centered topics.
How do you spend your time away from SFVA?
I spend most of my time away from work with my family. We have 2 daughters (14 and 11) as well as a son who is 6. I have become an avid and vocal volleyball fan after spending many hours watching and driving to club volleyball games. Exercise is my key to sanity. I love to hike and currently swim daily at 0545 as a member of the North Bay Aquatics Masters Swim Team. For vacations I love to go back home to South Carolina where I enjoy spending time in the marshes catching crabs and on the beaches looking for shark’s teeth and reading.
Interviewed Winter 2012