For the past 40 years, the USF Family and Community Medicine Residency Program at San Francisco General Hospital and Trauma Center has trained over 400 family doctors, one of which includes our own Dr. Kimberly Chang.
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.
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.”
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.”