The faculty in the fledgling UCSF Family and Community Medicine Residency Program at San Francisco General Hospital pose for a photo in 1976, seven years after the medical specialty was established in part to address the nation's shortage of primary care doctors.
“Family practice is impossible.” That’s what pediatrician Don Fink, MD, heard when he and an intrepid group of UCSF faculty set out to create a new family medicine residency program.
Good thing this was not a crew who listened to conventional wisdom – the UCSF Family and Community Medicine Residency Program at San Francisco General Hospital and Trauma Center (SFGH) celebrates its 40th anniversary in March 2012. It has trained more than 400 family doctors who have cared for tens of thousands of underserved patients and advocated for millions more.
“In the late ’60s, most people had never heard of family practice,” says Peter Sommers, MD, an early director of the residency program. Emphasizing outpatient care was also met with skepticism. “When I started specializing in outpatient care, that was considered crazy, radical,” said Fink.
But not by his colleagues in the UCSF Division of Ambulatory and Community Medicine. Led by Robert Crede, MD, they were pioneers in developing models of primary care. “Bob Crede was ahead of his time,” says Sommers.
They were also open to an idea outside the mainstream: the family as the central unit of care. Fink, for one, had learned during house calls that “if I didn’t understand family dynamics, I wasn’t going to be successful in delivering the care children needed.”
UCSF was ripe territory, therefore, when a new medical specialty was established in 1969 — family medicine. With the rise of specialists and the decline of general practitioners, the nation was facing a shortage of primary care physicians. The new specialty would help fill the gap.
Yet family medicine was controversial, says Fink. People were more supportive of developing sub-specialists rather than generalists.
State legislatures around the country soon pressed medical schools to start family practice residencies. In particular, they wanted physicians for hard hit rural areas and inner cities.
Navigating Uncharted Waters
UCSF needed a leader for this rather herculean task, and Fink got the job. UCSF was one of just three institutions nationwide to focus the residency on the urban — rather than the rural — underserved. They also decided they “must understand the patient within the context of the community, not just the family,” says Fink.
UCSF’s longtime partner in public health, SFGH, stood out as the ideal training ground for the fledging program. Frank Curry, director of the San Francisco Department of Public Health, proved a strong advocate by providing city and county funds to help launch the effort.
The job turned out to be a bit more than Fink bargained for. As part of the government’s War on Poverty, the Office of Economic Opportunity awarded SFGH a grant to improve outpatient services, including establishing a family health center and a satellite community clinic in the city’s South of Market neighborhood. Both clinics became key to training residents — and fell under Fink’s purview.
“In 1971, I went to SFGH and tried to put the pieces together,” Fink says. He began recruiting faculty; the first was Joanne Donsky, MSW, who is still with the program. Sommers, MD, now professor emeritus of family medicine, and others followed.
Two fourth-year UCSF medical students, Bill Gerber and Robert Drickey, helped create the groundwork and then became the inaugural residents in 1972. “They were our guinea pigs,” says Fink.
Reactions from the medical community ran the gamut from supportive to skeptical. “The standard dissent was that we could not master internal medicine, pediatrics, obstetrics and surgery in three years. They didn’t understand that basic skills would be adequate to take care of 90 percent of what presented in an outpatient setting,” explains Fink.
By 1973, they had assembled the first full class of residents and recruited a director, Robert Massad, MD. “We got — and still get — an incredible array of people from around the country,” says Sommers. One resident was Ron Goldschmidt, MD, who had been working at the Haight Ashbury Free Clinics.
“It was very exciting to be paving the way,” recalls Goldschmidt, a longtime professor of family medicine at UCSF. “Everywhere we went, no one knew what to make of us … There was a lot of on-the-fly creating of curriculum. I remember working out my own rotation with the chief of surgery.”
They were heady days, he says. “The faculty, residents and many of our colleagues were all supercharged by our social and political mission — health care equality for the poor.”
“Because the residents were activists, we took plenty of gust from them,” says Fink. “But that was good. We all shared the same values, so the arguments were about the best way to learn. It was productive ferment."
Holding Firm to its Heart
That ferment led to innovations that have helped make the program a magnet for exceptional students.
Goldschmidt, for example, started a family medicine inpatient service at SFGH in 1979 directly linked to the community clinics, enhancing both patient care and physician training. The residency director in the 1980s, Denise Rodgers, MD, forged important collaborations with hospital leadership to elevate primary care and continually fought funding cuts. “She was one of our heroes,” says Sommers.
Such creativity continues today. “I like to joke that we change our curriculum every year because we are always innovating,” says Teresa Villela, MD, residency director since 1999 and a 1992 program graduate. For example, current residents are steeped in team-based care as a way to better treat chronic conditions and manage work overload. “With diabetes, for instance, so much care is required that no clinician can do it alone,” Villela explains. Residents are spending more time in outpatient clinics to enhance continuity of care. The family health center that Fink launched years ago today has almost 40,000 patient visits a year, many managed by residents. And patient-centered care is a major emphasis.
Yet at its core, the residency has stayed true to its roots.
“We still have our values of family-centered medicine in the context of urban underserved communities,” says Kevin Grumbach, MD, chair of the Department of Family and Community Medicine, a 1985 graduate of the UCSF School of Medicine and a 1988 program graduate. “That’s what makes our training truly unique — this marriage between the academic excellence of UCSF and the mission-driven ethos of SFGH.”
Residency Graduates Thrive Serving Communities
Here are four graduates of the UCSF Family and Community Medicine Residency Program at SFGH who are doing the program proud.
Kimberly Chang, MD, SFGH, 2002
Family Physician and Site Director, Frank Kiang Medical Center, Asian Health Services
Seven years ago, Kimberly Chang began noticing a troubling trend among her young female patients at Asian Health Services (AHS), a community health center in Oakland’s Chinatown. The teens were coming in repeatedly with sexually transmitted diseases and bringing friends to be checked. Chang began asking them questions, eventually learning the girls were being sold for sex.
“We looked around and saw there were no services for them; those only came into play after they’d been arrested for prostitution,” Chang says.
She viewed the young women not as criminals but as victims. Many were of Southeast Asian descent whose parents had fled war zones. “There were lots of family issues, lots of depression,” says Chang.
Her colleagues and community activists started a program, Banteay Srei, to help sexually exploited girls. Chang works with this program, which provides counseling, peer support and classes in women’s health. She also has trained others how to recognize signs of sexual exploitation and has advocated for victims locally and nationally. In addition, she provides medical expertise for human trafficking task forces in the Western Pacific (Palau, the Marshall Islands and Micronesia).
The New York Times recently wrote that AHS is “in the vanguard of a new public health approach to treating American-born minors lured into the sex trade.” In addition, the Institute on Medicine as a Profession honored Chang for her efforts with a 2011 Physician Advocacy Merit Award.
The experience reflects what Chang finds so compelling about family medicine. “You can look further upstream to the social, economic and political conditions that create an environment where disease and illness thrive, and address root causes,” she says. “You can also have a broad impact by getting involved with policy, advocacy, community organizing and public health.”
Kara Odom Walker, MD, MPH, MSHS, SFGH, 2007
Assistant Clinical Professor, UCSF Department of Family and Community Medicine
Growing up, Kara Odom Walker didn’t know any doctors in her community and watched family members struggle to access health care. Today she’s giving back to communities like her own by researching health disparities.
“I’ve always been interested in the big picture,” says Odom Walker, who studied engineering and has a master’s in public health from Johns Hopkins University. “When I trained in the refugee clinic at SFGH, I started to think about how to better organize health care for those who don’t understand the system.”
She pursued that quest after residency through the prestigious Robert Wood Johnson Foundation Clinical Scholars Program at UCLA. When she arrived in Los Angeles, the public health system was in chaos because Martin Luther King Jr.-Harbor Hospital, a large public facility, had just closed.
Odom Walker worked with many community organizations to address the new gaps in health care, including surveying older African American and Latino residents in South LA to assess their unmet needs. “It was really an eye-opening experience in how to partner with communities to make a difference at the local level,” she says.
Odom Walker returned to San Francisco and joined the faculty at UCSF with fresh knowledge of how a fragmented health care system can lead to poor access and delays in care. She is now trying to understand from a patient perspective what makes for high quality, coordinated care.
The young clinician-scientist also continues to care for the underserved at SFGH. “Having those ties to my patients makes me more motivated and passionate about what I do with my research,” she says.
Albert Yu, MD, MPH, MBA, SFGH, 1992
Director, Chinatown Public Health Center, San Francisco Department of Public Health
Clinical Professor, UCSF Department of Family and Community Medicine
Albert Yu loves the diversity of family practice: the range of ages, the wide scope of clinical problems, the multi-layered focus. “I get to look at not just the disease, but the person and that person’s context — her family, where she lives, where she works, her culture. All impact how someone experiences health and how I need to formulate decisions,” he says.
Yu gets such variety in spades as director of the Chinatown Public Health Center (CPHC) in San Francisco. He came to CPHC in 2007 after a long and varied career at UCSF. “I’d always wanted to work in public and community health,” he says. Caring for underserved Chinese also appealed to Yu, an immigrant from Hong Kong.
His days are a whirlwind of managing the center, teaching residents, collaborating with community partners and treating patients. Right now he’s knee-deep in redesigning how CPHC delivers primary care.
“The traditional one-to-one patient-doctor model is not as effective for patient outcomes as it could be,” he explains. “Instead, we are creating teams to better support the delivery of services without the physician having to drive it.” They are also developing disease registries to capture all CPHC patients with chronic conditions so the team can conduct outreach. “With the old model, if the patient doesn’t come in, I don’t take care of the problem,” he says.
Engaging in the center’s myriad public health activities also keeps Yu hopping, such as raising awareness of Hepatitis B. Despite the demands, he still finds time to see patients. “They provide the meaning and purpose behind everything we do,” he says.
Patricia Zayas, MD, SFGH, 1991
Chief Medical Officer, La Clínica de La Raza
The sheer volume of patients visiting La Clínica de La Raza is daunting — 68,000 in 2010. And that number is growing.
“Even if we work as fast as we can, there are more patients than we can serve,” says Patricia Zayas, chief medical officer of the Oakland-based community health center, which has 26 sites spanning three Bay Area counties. “We need to step outside the way we practice today and move to new models to meet the demand.”
Innovating to improve care is nothing new to Zayas, who arrived at La Clínica fresh from residency. With her bicultural roots — she was born in Cuba and raised in the U.S. — she felt drawn to the center’s sizeable Latino population.
She started in the teen clinic and soon saw the need for family practice-style care for pregnant teens and their babies. Her vision led to the highly successful Teens and Tots program, where a multidisciplinary team delivers primary care to teen moms and their kids, along with health and parenting education.
Zayas then moved on to run school-based clinics. “It was very rewarding to be involved in the fiber of the lives of teenagers,” she says. Zayas still cares for pregnant teens one day a week. “It’s my favorite day,” she adds.
Since being named chief medical officer in 2005, Zayas continues to shake things up. “Our huge challenge right now is gearing up to participate meaningfully in health care reform,” she says.
They are moving to team-based care, integrating more behavioral health services, and expanding clinical sites, to name a few projects. “It’s a really exciting time to be working in medicine,” she says. “I believe family practice docs can be one of the solutions to health care reform.