Out & About...The Artisan Cheese Trail

Page 14

Q & A with the Interim Chancellor & Dean Page 8

10 Questions ....Spiritual Care Services

Page 6

Spring 2014

1 Continued on page 2

The Residents Report

in this issue

Accountable Care 1Lexicomp Mobile App 2

Incentive Update 4GME Diversity 510 Questions 6

Question and Answer 8Compassion Fatigue 10Out & About: Brewery 12

Out & About: Cheese 14Best of the Bay Area 16

SFGH Library 19GME Cypher 20

Sustainability Box 20

Building a System of Accountable Care at UCSFAmi Parekh, MD, JDMedical Director, Health System InnovationAssistant Professor, Department of Medicine, Division of Hospital Medicine

In the US we can be proud of many as-pects of our health care system such as our ability to treat some of the most com-plex and life-threatening conditions in the world; however, our fragmented health care delivery system has, until now, lacked an ability to contain the high cost of health care and demonstrate improved health outcomes at a population level. There-fore, as we look to the future of American Health Care, the main question is: How do we maintain our technical and scientific expertise while tackling the high costs of

care and improving the outcomes of care for our population?

There is a lot of hope that Accountable Care Organizations (ACOs) will be part of the solution. Accountable Care Orga-nization is a term coined by the federal government for voluntary partnerships between health care providers to deliver tightly coordinated, high-quality care to their Medicare population. If the group of providers can also show that they have reduced the costs of care for this popu-

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lation, they have the opportunity to share in the cost savings. The concept is based on the theory that if providers have a financial stake in improving quality and decreasing costs of care for a popula-tion, they will reduce unnecessary high cost, high-volume care and increase the provision of high-quality but lower cost care; in other words, they will provide high value care. Although the term ACO technically applies to populations for whom Medicare is the payer, commercial payers have been encouraging similar partnerships amongst providers through innovative payer-provider con-tracting. Over the course of the last two years over 400 ACOs have been created across the country. Some of these are part of the Medicare program, but most are in partnership with private insurance companies. The basic structure of a commercial ACO is a partnership between a payer and a set of provider organizations to deliver coordinated care for a given population, such as an employer group or attributed set of patients. These partnerships are different from traditional payment contracts entered into between payers and providers -- in these new models of contracts, providers are at risk for the total cost of care of the population and may have additional financial incentives to meet specific quality metrics.

Here at UCSF Medical Center, we are currently a part of two accountable care arrangements. One is for employees of the City and County of San Fran-cisco (CCSF) and the other is for employees of the University of California (UC). In both cases, these employers were faced with high costs of health in-surance for their employees and therefore worked with the health plans to develop ways to reduce the high cost of health insurance. For CCSF, the health plan partner is Blue Shield of California and for UC the partner is HealthNet. In both of these cases the health plans partnered with UCSF Medi-cal Center, two Dignity Hospitals in San Francis-co, and Hill Physicians Medical Group to be the provider network in an accountable care arrange-ment.

The goal for these groups is to work together to provide high-quality of care to the members across the continuum of care for an overall reduced cost. As we have worked in these partnerships over the past years, we have learned that each part-ner brings something unique and valuable to the table and together we can truly improve the quality of care patients receive and reduce unnecessary utilization. For example, health plans have highly accurate and reliable data on the actual costs of care across settings, while providers have more accurate understanding of the clinical demograph-ics of a given population. By working together, we are able to gain a more complete view of our pop-ulation’s health care patterns, allowing us to make focused improvements in our delivery system.

Over the last two years we have focused on both outpatient and inpatient interventions and have seen a reduction in the costs of care across both populations. In the outpatient setting, we have fo-cused on increasing access to primary care and urgent care so that patients can see an outpatient clinician when they need to, instead of having to go to the emergency room. The average ER visit costs between $900 and $1200, whereas the aver-age PCP visit costs between $60 and $250. From the patient perspective, for one of our ACOs, a trip to a physician’s office has a $20 co-pay; whereas a trip to the emergency room has a $75 copay. Ensuring patients have access to the right level of care can have a large impact on overall costs. We have also worked on improving access to behav-ioral health services as patients with behavioral health co-morbidities often utilize medical care at a higher rate when their behavioral health needs are not adequately addressed. For patients who have complex medical needs, we have worked to ensure they are involved in outpatient complex case management because this has been shown to reduce the frequency of hospitalization for the chronically ill. Finally, for the generally healthy ACO patient we have developed interventions to improve health education and self-management abilities.

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For ACO patients who do become hospitalized, they are followed by an inpatient care transitions manager, who helps coordinate their discharge and transition needs and continues to be a point of contact for the patient for 30 days after discharge. This high-touch care has helped avoid readmis-sions and ensures patients get the care they need both during and after hospitalization.

To date, through our multiple interventions, we are starting to see cost savings while maintaining or improving the quality of care we are delivering for our patients. For example, for one of our ACOs, we reduced inpatient hospital days by 23% in 2013. In the other ACO, we have seen a 3 to 5% reduction in ED utilization over the last two years. We have also seen a trend towards reduction in readmis-

sions in both ACOs. Additionally, in one ACO we were able to increase the use of generic medica-tions by approximately 10%.

Through these partnerships, we are learning to work with providers with whom we haven’t histori-cally collaborated. While there is still much to learn about how to impact the costs of care for a large population, we have started to see that by work-ing together, we can, in fact, increase the value of care we deliver to a population.

If you have any questions about or are interested in getting involved in UCSF’s ACO efforts, please contact Ami Parekh at aparekh@medicine.ucsf.edu.

Our Lexicomp subscription allows you to download Lexi-Select and our formulary onto your mobile devices. The renewal code can be found online on the Lexi-comp page. On the right-hand side, there is an option “Mobile App Access,” click on that link and that will give you the new code. You will have to access your Lexi-comp account that was established when you first set-up the app on your device.http://www.crlonline.com/lco/action/home/switch

Lexicomp Mobile App Access

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Housestaff Incentive Update

Goal #1: Patient Satisfaction - On the patient satisfaction survey likelihood of recommending question, maintain an annual average (July 2013 – June 2014) mean score of 92.2 (50%) AND the average of all HCAHPS survey domains for the last quarter improve from 46th percentile to 60th (50%). .

Goal # 2: Patient Quality and Safety - Increase per-cent of patients discharged before noon from 17.6% to 20% for 3 of 12 months. T

Goal #3: Resource Utilization - Achieve a 0.5% re-duction in cost per discharge.

For those who would like more detailed information

about inpatient discharges, check out the Discharge Dashboard: http://dischdash.ucsfmedicalcenter.org (use your APeX login)

Glenn Rosenbluth, MDDirector, Quality and Safety Programs, GMEWe are excited to share with you the news that we have achieved 20% of discharges before noon for 3 months! This was one of our all-program Resident and Fellow QI Incentive goals for the year. All eligible residents and fellows will receive $400 for achieving this goal.

Metric Quarter 1 Quarter 2 Quarter 3 Comments

Patient Satisfaction:

Press-Ganey mean score of 92.2

AND

HCAHPS average of all survey domains at 60th percentile

nUnchanged, no improvement

kIncreased, but below target

k Increased, still below target

We’re making improvements in some areas, but not yet at our goal.

On Press-Ganey, overall we are at 91.0 for the year, but for the most recent period we were at 92.1 which is close!

On HCAHPS, we are at 55th percen-tile for the year.

Discharges Before Noon:

20% of our discharges before noon for 3 of 12 months

kImproving to-

ward goal

nOn track to

achieve goal

kGOAL

ACHIEVED!

Congratulations!We have achieved this goal! Prior

to 2013, the Medical Center had never had a month with 20% of

discharges before noon. We’ve now had 3, and achieved our goal.

Cost per discharge:

Achieve a 0.5% reduc-tion in cost per dis-charge

mImproving, on-

target

mSlightly down still

on-target

kNeeds

improvement!

As of the end of January, we are 0.3% above our budgeted amount.

Here are some things your team can do to reduce costs:

• Use an oral equivalent for H2-blocker or antibiotic• When doing a procedure, have ex-tra supplies available, but don’t open them until you need them• Minimize the number of lab draws each day

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Rene Salazar, MDAssociate Professor of Clinical MedicineGME Director of Diversity

Our seventh annual Diversity Second Look program was held on January 31, 2014. Several departments participated in this opportunity for applicants to revisit UCSF and learn more about our training programs, including our commitment to promoting diversity in our residency training programs. Activities included a discussion entitled “Diversity at UCSF-A Perspective from Campus Leaders” led by Dr. René Salazar, GME Director of Diversity. This was followed by a panel discussion with current housestaff led followed by a reception at Caña Cuban Parlor in San Francisco’s Mission District.

Special thanks to the following housestaff who participated in the panel discussion: Sarah Schaeffer MD, Willie Moses MD, Melissa Bent MD, and Kaija Romero MD. Over 40 applicants, faculty, fellows, and residents from several departments attended the evening reception.

Thank you to everyone who participated and to Andrea Cunningham who helped organize this year’s activities.

GME Diversity

For more information or to learn how you can get involved, please contact Dr. René Salazar, GME Director of Diversity via email (salazarr@medicine.ucsf.edu) or phone (415) 514-8642.

UCSF GME Also Participated in:March

Latino Medical Student Association Western Regional Conference UC

March 21-22, 2014Sacramento, CA

GME Diversity Advisory Group Meeting

March 24, 20146-7:30PMUCSF Multicultural Resource Center

April

Student National Medical Association Annual Medical Education Conference

April 16-20, 2014Washington, DC

Latino Medical Student Association National Meeting

Aprtil 25-26, 2014Houston, TX

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10 Questions from the Resident and Fellow Affairs Committee

Rev. Dr. Peter Yuichi Clark, PhD, Rev. Dr. Michele R. Shields, DMin, and Rev. Susan P. Conrad, MDiv, (left to right in the photo) an-swer resident and clinical fellow questions about working with Spiritual Care Services to care for patients and for the physicians at UCSF:

1. What is the mission of Spiritual Care Services?

Our primary task is to offer spiritual and emo-tional support to inpatients and their families and loved ones, no matter what their reli-gious faith (or even if they practice no faith at all). At the same time, caregivers – including physicians, nurses, and everyone else who has contact with our patients – need support too, and we gladly provide that care for you so that we all can better fulfill the Medical Center’s mission of “Caring, healing, teach-ing, and discovering.”

2. Who are the people working in this area? What is their availability, and how are they reached?

We are a team of staff and student chap-lains, representing a variety of faith tradi-tions, serving clinical floors at both the Par-nassus and Mount Zion campuses, including the adult Palliative Care Service and the

Inpatient Pediatric Palliative Program (IP3) at Parnassus. Staff chaplains are trained and certified in their discipline, and the stu-dents participate in a program called Clinical Pastoral Education, which is accredited and recognized by the U.S. Department of Edu-cation. A chaplain is available on-site 24/7 and can always be reached by paging 443-CARE [2273].

3. How can I identify situations and patient events that would benefit from this service?

A PDF list of “Top ten reasons to call Spiritual Care Services” can be found at http://ucsfspiritcare.org/materials-for-download/ and you can always consult with the on-call chaplain or the chaplain assigned to the clinical area where you’re working. If you do have a patient who would benefit from a chaplain’s visit, you can page us at 443-CARE or order a consult in APeX.

4. Why would residents and fellows want to seek Spiritual Care Services for themselves?

The responsibility you bear for patients’ medical care is daunting, and research indi-cates that depression, anxiety, and burnout occur at moderate to severe levels for over 50% of medical students, residents, and fel-lows. Chaplains can be a valuable resource to help you cope with the stress, exhaustion, and emotions that arise in your work, such as when you’re dealing with a patient’s death, a difficult family situation, an ethical dilemma, or other circumstance. We’re good listeners and we’re very willing to give you a few min-utes to vent, debrief, or collect yourself so that you can resume your duties in a better frame of mind.

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5. What type of educational programs can Spiritual Care Services provide?

We can provide workshops of any length from 20 minutes, as part of a staff meeting, to 60-minute in-services or longer, as need-ed and desired.

6. What are some of the workshops that you have led?

Compassion fatigue, caring for yourself, caring for others, conflict resolution, ad-dressing patients’ emotional needs, guided meditation, cultural and spiritual humility, fostering teamwork, case studies on spiri-tuality and ethics, and spiritual care at the end of life: these are just some of the top-ics we have addressed, and can address, in workshops.

7. How would I go about arranging a workshop for myself and my fellow trainees?

You can contact any of us (all three of us are in the UCSF global e-mail directory) or call our main office extension, which is 353-1941. You also can mention your request to the chaplain serving your clinical area, and she/he will relay the message.

8. What is the program for debriefings after Codes and other stressful events? How does this work?

Chaplains routinely respond whenever a Code is called at Parnassus or Mount Zion, and we provide support to family members and staff as appropriate. After the Code has ended, a chaplain will send an e-mail message to staff members, inviting you to a session (usually scheduled two days later) where you can talk about your emotional re-actions and learn coping strategies to deal with the stress. A chaplain is present and serves as the discussion facilitator. In the

past sixteen months, we’ve provided 51 de-briefing sessions to 503 staff members.

9. If I’m unable to attend a general debrief-ing, are there other options?

One-to-one sessions can be arranged if you are interested in talking with a chaplain af-ter a Code, or other stressful event, and you cannot attend the general briefing. This can be arranged by paging the on-call chaplain at 443-CARE or calling the main office at 353-1941.

10. Are there any suggestions for self-care or tips for being healthier at work?

A PDF card called “Seven steps to self-care” has helpful tips and can be found at http://ucsfspiritcare.org/materials-for-download/ you can ask any chaplain for a pocket-sized copy. In addition, please visit our Medi-tation Rooms, located near the main en-trances at both the Moffitt/Long and Mount Zion hospital buildings. These are spaces where patients, family members, and you are welcome to pray, sit in silence, or medi-tate. They are open every day from 7 a.m. until 9 p.m. Finally, please remember that we stand ready to help you anytime, day or night. Feel free to call us!

Spiritual Care ServicesMain Office Phone: 353-1941

Pager: 443 -CARE [2273]

Website: http://ucsfspiritcare.org/

A chaplain is available on-site 24/7 and can always be reached by pager.

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How do you think the recent affiliation with Children’s Hospital Oakland and the opening of the new hospitals at Mission Bay will affect resident and fellow education?

The opening in early 2015 of the new hospitals at Mission Bay will be a transformational landmark in our history. When we admit our first patients to the new UCSF Benioff Children’s Hospital, the Betty Irene Moore Women’s Hospital, and the Bakar Cancer Hospital, our residents and fellows will form an integral part of our state-of-the art care in each of the specialty areas these hospitals serve.

At the recent School of Medicine Leadership Retreat, which was focused on learning and learning environments, we featured a panel of residents. Joe Ebinger, Lindsay Hampson, Nathan

Rowland, and Amanda Sanders talked about how important it is to meet and work with different groups of people at UCSF. We are going to capitalize on the location of Mission Bay Hospital to design new programs for residents and fellows to collaborate with graduate students and postdocs on solving problems in human health. Prior to the opening of the new hospitals, its clinical faculty and staff will move into the Mission Hall building across the street. The building contains a learning center with classrooms and indoor and outdoor breakout spaces, ample conference rooms of different sizes, and a cafeteria. Mission Hall will allow us for the first time to co-locate certain departments and divisions in ways that will help increase collaboration. It also joins programs that are currently scattered across the city, including our global health programs, clinical and translational science programs, and the Department of Epidemiology and Biostatistics.

Many residents have told me they came to UCSF to be part of an institution that integrates great research with a deep commitment to caring for the most vulnerable patients. The affiliation with Children’s Hospital Oakland is an opportunity for us to live this commitment while expanding both the variety and the quality of resident and fellow education on both sides of the Bay.

We plan to share our respective expertise to provide a greater diversity of experiences and a critical mass of patients to enhance training, particularly in specialty areas. CHO has a world-class children’s trauma service and an extremely busy emergency room with over 50,000 visits each year. They also have outstanding clinical and research programs, for example in blood disorders.

Q & A With The Interim Chancellor & Dean

Sam Hawgood, MBBSDean, School of Medicine, UCSFInterim Chancellor, UCSF

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The rapidly rising cost of housing in San Francisco has received much nationwide publicity. Are there plans to increase the limited options for on-campus housing for residents and fellows?

I am acutely aware of the impact of the high cost of living and especially housing in San Francisco. It is presenting a major challenge to all of our trainees and many of our employees. We are looking to expand our housing options on campus, but that is a multi-year project and unlikely to provide short-term relief.

To expand availability for incoming trainees, we have changed our policy for housing by limiting UCSF housing tenancy to a two-year term. We are also working to develop more strategies for outgoing trainees to connect with incoming trainees to share housing resources, ideas and availability. We will continue to explore other options as well.

To what extent do you feel that your experience as dean of the School of Medicine will help you in your new role as interim chancellor?

Its hard to believe now, but when I first came to UCSF in 1982 as a research fellow, I intended to stay for no more than a couple of years. Like others before me, I then found that UCSF offered me unparalleled prospects for collaborations with remarkable physicians and scientists.

During my 32-year career at UCSF, I’ve experienced the culture from many perspectives: as a research fellow, a faculty member, division chief, chair of Pediatrics, and since 2008, as dean of the school. Each position provided me with new perspectives and insights on the institution and its interlinked mission of education, research, patient care and public service.

For the past six years, I have also served as a member of the Chancellor’s Executive Cabinet, which oversees all the major initiatives and addresses challenges the campus faces. Having thus gained a comprehensive understanding of the institution, I fell well prepared to take on the interim chancellor role during this transition.

As Chancellor, what challenge facing UCSF will be your first priority?

The priority of any interim leader is to maintain the momentum and carry the institution towards a successful and seamless transition to a new chancellor.

UCSF has a lot of exciting momentum right now, and I want to make sure we don’t miss a beat in taking full advantage of all the opportunities offered to us. In the era of the Affordable Care Act, how can we position UCSF to be a leader in innovative high-value health care? In this time of remarkable scientific breakthroughs, how can we be at the forefront of innovation and discovery? In this dynamic environment, how can we make sure that our students and residents not only learn to work effectively in today’s world, with today’s knowledge, but are primed to lead the changes needed for tomorrow?

We are starting to implement our new strategic plan for the UCSF health system. The goal is not just to remain a top academic health center but to play the leading role in a regional healthcare delivery system. Residents and fellows will play a critical part, especially in building a culture of continuous process improvement to optimize our delivery systems, enhance the patient experience, reduce waste and improve the safety and quality of our care. Many of our trainees are already deeply engaged in this effort, and I really appreciate their hard work and innumerable contributions.

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Jamine Ergas, PsyD Faculty and Staff Assistance Program

Residency and fellowship training is a very stressful time in a physician’s life. The long hours, multiple shifts, and difficult rotations can be a significant source of stress. In addition to the demanding aspects of the work itself, many residents and fellows have the added stress of a recent move, getting married, and/or starting a family. There are often not enough hours in the day to take care of personal or relationship needs. Many residents and fellows feel exhausted in the free hours they do have and need that time to recuperate before returning to work. All of these factors are major contributors to the stress level of residents and fellows, and to some extent, that stress is obvious and expected. However, there is another contributing factor that also impacts the wellbeing of resident physicians – the emotional stress of caring for sick, injured and/or dying patients.

Physicians, like many other helping professionals, come into regular contact with traumatized individuals. Studies conducted on the role of empathy in patient care have found that “…empathic doctors and nurses provide higher quality care and have patients who express higher satisfaction with service” (Regehr, Goldberg, and Hughes, 2002, p. 510). At the same time, the process of caring for and providing empathic treatment to traumatized patients puts physicians at risk for compassion fatigue, which Charles Figley (1995) defined as “the emotional residue or strain of exposure to working with those suffering from the consequences of traumatic events.”

The emotional impact of patient care may not always be obvious. In fact, individuals may unconsciously or consciously suppress difficult emotions until a shift or even an entire rotation is

over. Sometimes, it is not until something in our personal life starts to suffer that we realize work-related interactions impact our psychological well-being. Although it makes sense to keep emotions as much “in check” as possible when caring for patients, it is also important to recognize that the work you do can be emotionally draining, and to find the space to acknowledge and process these emotions and establish the skills to cope.

Emotionally Difficult Aspects of Patient Care

• Patients who die alone• Grief of family members• Very sick patients• Patients who have a condition similar to

your own or someone close to you• Patients with whom you particularly connect• Suicidal patients• Sick and/or dying children• Neglected/abused children

The emotional impact of patient care can manifest in various ways. You may feel down, not quite yourself, anxious, hopeless, or unable to sleep or to concentrate. These feelings, along with those listed below, are all symptoms of what, in the research literature, has been interchangeably referred to as “burn-out”, secondary traumatic stress, and compassion fatigue.

Signs of Compassion Fatigue

• Not wanting to go to work • Changes in behavior – e.g., hypervigilance • Recurring thoughts of the patient or situation• Withdrawing from loved ones• Apathy towards work and/or patients• Increased substance use

Compassion Fatigue: An Occupational Risk for Physicians

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Prevention/Self-Care

Given the intensely stressful demands of your profession, coupled with consistent exposure to the suffering of patients, it is important to be on the lookout for the signs of compassion fatigue. Once identified, acknowledge and examine how your work impacts you emotionally. Seeking support from other residents, fellows, faculty mentors, friends, family, partners, spiritual counselors, and/or a therapist is an essential component to mitigating compassion fatigue. In addition to such social supports, your department’s Residency or Fellowship program can play a crucial role in preventing compassion fatigue, for example by offering trainings or group sessions for the purpose of processing feelings related to patient care. This not only normalizes the fact that residents, fellows, and attendings are emotionally impacted by their work, it also sends the message that addressing this impact is of vital importance to the well-being of physicians and patients alike.

Tips for Preventing Compassion Fatigue

• Make time to do things unrelated to your work. This may be challenging for busy residents and fellows, but it needs to be a priority!

• Take time off• Regular exercise and a healthy diet• Talk to someone about the emotional aspects

of your work• Get supervision• Identify what is meaningful to you in life and

connect with it• Focus on the meaning and joy you find in

caring for your patients

Assessing Compassion Satisfaction & Fatigue

If you are interested in assessing your risk of developing compassion fatigue, you can access the Professional Quality of Life: Compassion Satisfaction and Fatigue Scale (ProQOL)

developed by Beth Hudnall Stamm, online at www.isu.edu/~bhstamm or www.proqol.org.

Conclusion

Many of you are under an extraordinary amount of stress and may have more demands on you now than ever before. It may feel like you do not have enough hours in the day to stop and ask yourself, “How am I doing?” Nevertheless, taking time for yourself to recoup from your busy shift or rotation will go a long way toward preventing compassion fatigue. Incorporating self-care into your routine will enable you to stay present and engaged with the important work you do. Not only will you benefit from taking care of yourself, your patients will too.

If life starts to feel like it’s too much, reach out to someone. We at the Faculty and Staff Assistance Program can provide you with counseling services as well as referrals for therapists in the community. FSAP services are free and confidential and available for both personal and work-related issues. Please contact us at 415-476-8279 or visit our website at http://www.ucsfhr.ucsf.edu/assist for more information.

References

B. Hudnall Stamm, 2009. Professional Quality of Life: Compassion Satisfaction and Fatigue Version 5 (ProQOL). /www.isu.edu/~bhstamm or www.proqol.org.

Figley, C. (1995). Compassion fatigue: Coping with secondary traumatic stress disorder. New York: Brunner/Mazel.

Regehr, C., Goldberg, G., & Hughes, J. (2002). Exposure to human tragedy, empathy, and trauma in ambulance paramedics. American Journal of Orthopsychiatry, 72(4), 505-513.

Huggard, P. (2003). Secondary traumatic stress: Doctor’s at risk. New Ethicals Journal. September 2003, pp 9-14.

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OUT & ABOUT from the Resident and Fellow Affairs Committee

Brewery Crawl Nilay Sethi, MD, PhDInternal Medicine Resident, PGY2University of California, San Francisco

What is the most popular beverage after water and tea? What do you get when starch is saccharified and the resultant product undergoes fermentation? What do I need after a long clinic-day saturated with complex patients? The answer to all these and many other questions is beer. Once only a wide-eyed observer of its consumption as docu-mented by numerous childhood photos, I have since adopted a different position on fermented saccharified sugar. Transcending the casual and often-time passive role of a consumer, I have now embraced the responsibility of an enthusiast. And what better way to celebrate my new function in society than to learn about the origin of these tasty brews by traveling to their respective birth sites.

Here, you will find, and hopefully enjoy, the fruits of my elective investigation: a short description of my favorite breweries in northern California listed

in order from incredibly enjoyable to unpredictably pleasant.

1. Lagunitas Brewing Company

Located less than an hour north of the city in Petaluma, Lagunitas stood out among the rest owing to its high marks in many domains not limited to great quality beer, a well-designed tour, and an exciting restaurant ambience oc-casionally augmented by live music. Patrons usually share benches in the communal out-door seating, which offers a suitable setting for a collection of individuals united by an en-thusiasm for beer and understandably inspires a sense of solidarity. The weekday tours are special. Self-identified participants are escort-ed to a spacious lounge resembling a hybrid between a bachelor pad and renovated frat house. Five free sample-size pours of Laguni-tas’ seasonal beers are distributed. During my visit, the dialogue began abruptly when a husky red-bearded tour guide demanded our atten-tion from behind the bar. He initiated a unique narrative less focused on specific brewing de-tails and production stats. Rather, he engaged the audience by describing the genesis of the brewery, which is notably emboldened by mis-adventures and imbued with character.http://lagunitas.com

2. North Coast Brewery Company

Born in 1988, North Coast is located along the Mendocino coast in Fort Bragg, home of the Glass Beach. Considering the ability to visit their museum, restaurant and/or gift shop, there are many ways to absorb the North Coast experience. I decided to visit their gift shop, which was adequately stocked with their brews. Among these beers, two Belgium-style

Where members of the UCSF Community recommend their favorite scenes outside UCSF

13

ales caught my attention and taste buds. The farmhouse ale Le Merle, which means Black-bird, is a saison derived from brewing tradi-tions of the Flanders region of Belgium. This straw-colored, hoppy ale carries a subtle tropi-cal fruit aroma. The Good Food award-winning PranQster is a Belgium-style golden ale. True to its name, it displays a healthy golden color in addition to providing a robust fruity flavor. http://www.northcoastbrewing.com

3. Redwood Curtain Brewing Company

A little south of Redwood National Park in Humboldt County, Redwood Curtain is located in Arcata. It is a unique establishment akin to your favorite cafe except that it sells brews. Instead of ordering a venti coffee-to-go, one can fill a personalized growler with their favor-ite brew. Grab your favorite board game or word puzzle from their wide selection and chal-lenge your friends to a game-filled afternoon. Come on the right night and you can test your knowledge in a trivia competition, take part in a cribbage tournament, or enjoy a musical per-formance. Among their large array of brews, my personal favorites include the Trippel and Imperial Gold Ale. They also served a collec-tion of sour beers such as the Citra Pale Ale and Ipa Dry Hopped with Citra. http://www.redwoodcurtainbrewing.com

4. Russian River Brewing Company

A restaurant brewery, Russian River is lo-cated in the heart of downtown Santa Rosa. We were able to take a leisurely stroll down 4th street, passing by murals, fountains, court-yards and live performances while waiting for our number to be called. After being seated, my friends and I enjoyed a pizza lunch comple-mented by a flight of sample-size beers served in a unique wooden tray. Two flights were of-fered - hoppy California style ales and Belgian inspired ales. In addition to the popular Pliny the Elder, I particularly enjoyed the golden ale

Sanctification and the darker red ale Salvation. Like Redwood Curtain, they also serve a large selection of sour brews as part of the Belgium cohort. http://russianriverbrewing.com

5. Lost Coast Brewing Company

Another restaurant brewery, Lost Coast is lo-cated in Eureka along Highway 101 just before it bends around Arcata Bay. The restaurant generates a stimulating atmosphere. In ad-dition to the great brews and American-style food selection, it stocks arcade games and a pool table in the posterior aspect of the es-tablishment. As for the brews, my favorite is their pale ale, which took home the gold at the Humboldt county fair in 2004. Another popular choice is Downtown Brown, which, not surpris-ingly, is a nut-brown ale carrying a mild crystal malt flavor uniquely integrated with a strong porter taste. http://www.lostcoast.com

Honorable mentions:

21st Amendment Brewery

Located in SOMA near downtown SF, this brewery is great for grabbing a quick one be-fore heading to a Giants game as it is located walking distance from AT&T Park.

Santa Cruz Brewery

Nice cozy brewery with ample outdoor seating located a short distance away from the board-walk/beach filled with miniature golf, bowling, and every arcade game a kid (or an adult in our case) could imagine.

Bear Republic Brewery

Conveniently located in downtown Healds-burg, this brewery has a large outdoor patio upon which one can enjoy a meal and their beer served in either 3.5oz or full pours.

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OUT & ABOUT from the Resident and Fellow Affairs CommitteeThe Artisan Cheese Trail

David M. Jablons, MD, FACS Professor and Chief of Thoracic Surgery, Program Leader of Thoracic Oncology, and Director of the UCSF Thoracic Oncology Lab

I’m about to let you in on one of the best kept secrets of the Bay Area – the artisan cheese-making movement. It was Spanish priests who started making cheese from the milk of mission livestock in the early 1800s. Later European immigrants, mostly Italian and Swiss families, established dairies in the lush pastures and rolling coastal hills of coastal west Marin. In the mid-ninetieth century, there were over one-hundred individual family farms in west Marin and Sonoma with dairy operations flourishing during the Gold Rush. Initially they supplied butter (milk would spoil absent refrigeration), but in the early 20th century as the Bay Area developed and refrigeration became available, fresh milk could be supplied and the dairies thrived. With the advent of milk price regulation, however, and the emergence of industrial factory dairies in the Central Valley, local West Marin dairymen faded from the scene as they could not compete. Sadly, today the total number of family run dairies in west Marin is down to about fifteen!

The Marin French Cheese Company,

located in rural west Marin, was founded in 1865 by Jefferson Thompson and produces cheeses under the Rouge et Noir brand name. It is the oldest cheese manufacturer still in operation in the United States. In 1979, Laura Chenel became America’s first commercial producer of goat cheese when she began producing chèvre in the west Sonoma town of Sebastopol. After several months of working to sell her product to local markets (with mixed success, due to American unfamiliarity with goat cheeses), she received her first major opportunity when Alice Waters of Chez Panisse placed a standing order for her cheese in 1980. This may have been the first American instance of goat cheese salad. www.marinfrenchcheese.com

This brings us to pioneers Sue Conley and Peggy Smith who took a hippie trip to San Francisco after finishing their degrees at the University of Tennessee in 1976. Each established careers in San Francisco’s most famous kitchens: Peggy spending 17 years at Chez Panisse, and Sue co-owning Bette’s Oceanview Diner in Berkeley. By the early 1990’s, Peggy and Sue were ready for a new challenge. They launched Tomales Bay Foods www.cowgirlcreamery.com/pt-reyes-shop-creamery in Point Reyes, a marketing vehicle to help west Marin’s farms and dairies get their delicious products into the hands of the Bay Area’s finest chefs. Their first location, a renovated hay barn in downtown Point Reyes, makes a great first stop on your tour and also houses their original creamery (where they currently make Red Hawk) at the entrance to the building. Using milk from neighboring Straus Family Creamery, they began making delicious fresh cheeses. The creamery is called Cowgirl Creamery www.cowgirlcreamery.com and now has cheeses in over 500 markets. The Tomales Bay Food’s building has a nice view into the creamery and all of the ingredients (wine, salumi, olives, bread, etc.) you will need as well as great cheese, for a wonderful picnic.

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After touring the Creamery, walk around Point Reyes Station, a small hamlet at the southern base of Tomales Bay and the gateway to the Point Reyes Seashore National Park. Visit Toby’s Feed Barn www.tobysfeedbarn.com on the main drag –they have good espresso drinks in a small kiosk in the hay barn alley and tons of local fare, food, books and sweatshirts and the like inside. Two restaurants deserve special mention here: Osteria Stellina www.osteriastellina.com is an authentic Italian and California cuisine mélange with outstanding locally produced meats, shellfish, pastas and cheese dishes. The Sir and Star at the Olema Inn www.sirandstar.com has received rave reviews. And then there is Saltwater www.saltwateroysterdepot.com , a great new restaurant, oyster bar, and local hang-out just a few miles across the Bay in Inverness that’s worth a detour.

But this is about the cheese. Head north out of Pt. Reyes for three miles and just past the Tomales Bay Oyster Company http://tomalesbayoysters.com/ is the Giacomini Dairy and home of the Pt. Reyes Farmstead Cheese Company www.pointreyescheese.com. The Giacomini family has been a pioneer in the conversion of dairying from bulk milk production to farmstead artisan cheese production. They produce California’s only classic-style blue cheese, Original Blue, which has become a local classic and recently won a prestigious SOFI (Specialty Outstanding Food Innovation) award. They are open to the public infrequently, but do rent out for events (at their beautiful facility called “The Fork”) and have cooking classes so check their website.

After winding along the inordinately beautiful Route 1 headed north up through Marshall, you will pass many amazing places to stop and have oysters: Hog Island Oyster Company Farm www.hogislandoysters.com, Tony’s Seafood, or stop for lunch and a to-die-for view at Nick’s Cove and Cottages www.nickscove.com (great place to stay as well). If you have been smart enough to sign up in advance, go visit Marcia Barinaga and

sample her amazing aged sheep’s milk cheeses and tour Barinaga Ranch, which runs along the top of the Marshall Ridge and has spectacular views of the Bay and Inverness on a clear day. www.barinagaranch.com

If at this point you have not totally become bloated on remarkable cheeses, wine and/or beer and oysters, then take a break and rent a kayak for a surreal early morning paddle along the shore or a more strenuous ride in the afternoon against the winds and tide.

Continuing north after passing thru Walker Creek (my favorite part of the drive) you deadhead straight into the town of Tomales. At the outstanding Tomales Bakery on Hwy. 1, you can provision with great breads and scones, puff daddy’s, cinnamon raisin wheels, and the like, and then head west on Dillon Beach Road for a mile and half and take your first right on Middle Road and come visit us at Toluma Farms and Tomales Farmstead Creamery www.tolumafarms.com. Our family purchased the farm over a decade ago. We have worked steadfastly to restore it, certify the land organic and repurpose the prior Jersey cow dairy into a goat and sheep dairy. Just this year we began making our very own farmstead goat and soon-to-be mixed milk (goat, sheep, and eventually cow) soft ripened and aged cheeses. Sign up on-line for tours that are typically the first Sundays of the month.

Heading further north on Middle Road you come to the historic ranching town of Valley Ford where the local market sells many of the regions local cheeses and McClelland butter. www.mcclellandsdairy.com You can also drop in our friends Andrew and Curtis at di Bufala Dairy who make water buffalo milk cheese and amazing gelato. Continue north out of the town and take your first right to head to Occidental and Freestone. Sample delicious local grown Phelps Winery http://josephphelps.com/ chardonnay and pinot noir and stop at the Wild Flour Bread Bakery

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BEST of the Bay Area: My TOP Restaurants - Part TwoR. Hirose, MD (unofficial self-appointed Vice Chair of Food and Wine), Department of Surgery, UCSF

This is the second part of a very personal, extremely bi-ased, non-objective list of the absolute best eats in the San Francisco bay area.

BEST Ramen: Tonkotsu Ramen at Izakaya So-zai – nice creamy broth, firm toothy noodles…al-though newcomer Waraku will give it a good run for its money. Close to Parnassus!

BEST Karaage: Waraku as mentioned above – go for the tonkotsu ramen, but order the kara-age– the karaage is outstanding crispy and not heavy as karaage can be.

BEST Southeast Asian Noodle Dish: Mandalay Special Noodle at Mandalay. No, not a typical dish like pad thai from Marnee Thai, which isn’t bad but the mandalay special noodles (with chicken) is a unique winner. The Burmese favorite has been

cranking out excellent food for over 25 years. Just enjoy the Christmas ornaments hanging from the season and taste the best Burmese food around. The mango salad and the mandalay beef are all standby’s, but the mandalay special noodles will have you craving between visits.

BEST Chinese Noodle Dish: Jajamen at King of Noodles – don’t miss the xiao long bao (Shaghai soup dumplings) as you stumble into this hole in the wall, with grandma handpulling the noodles in the back.

BEST Scallops: Live Scallop nigiri (special) at Ebisu – the fresh live scallops at the local Sushi place close to UC is hard to beat.

Best Uni: Uni is definitely an acquired taste, but once you get over the hump and can actually en-joy the briny finish that makes the consumer fully aware that they are enjoying the fresh bounty from the sea, the creamy sweetness of sea urchin roe is highly addictive. Uni from Hokkaido (when they have it) at Sushi Ran in Sausalito is beyond the fresh uni from Mendocino or Santa Barbara. Ask if

http://wildflourbread.com/ for surreal breads and scones. No more than a couple of hundred yards up from the bakery is the new Freestone Artisan Cheese shop. http://www.freestoneartisan.com/ Stop in and talk to owner/cheese monger Omar (tell him I sent you) and sample and buy any of the locally produced artisan cheeses as well as many of the phenomenal artisan cheeses he imports from around the country.

At this point, you may be satiated, but just in case you have more cheese tasting left in you I highly recommend on your way back detouring thru Nicasio to visit the Nicasio Valley Cheese Company http://www.nicasiocheese.com/ (open for cheese tastings, no need for appointment) and tasting their many delicious organic cows’ milk fresh and aged cheeses.

Hopefully, this has given you a few ideas about a scenic and cheese-rich day out in the beauty of west Marin, probably the best-kept secret of the Bay Area. But if you still aren’t satisfied or your interests are truly piqued then go online and check out the other farms and cheese operations along the trail that are open to the public. Among the 29 producers listed on the Sonoma Marin Cheese Trail map, web site http://cheesetrail.org/ and mobile app, 21 are open for regular or periodic tours and tastings, or for visits by appointment. Guided cheese tours are also popping up, including a five-hour jaunt that includes four creameries, tastings of 30 cheeses, and a picnic ($152). http://www.foodandfarmtours.com/

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they have it in from Japan. Great sushi bar. Fresh fish flown in from Tsukiji Fish Market in Tokyo (where one has to visit to believe) – you can’t go wrong taking a date to Sushi Ran.

BEST Crab: Roasted garlic crab at Thahn Long (add addictive garlic noodles) – Way out there in the Outer Sunset, the An family introduced the world of San Francisco to their fusion version of Vietnamese cuisine and to their family secret rec-ipe for crab in 1971 at Thanh Long, and the rest is history. Then came Crustacean, and then oth-er outposts in So Cal, etc. The real deal is still at Thahn Long where their famous garlic noodles (I think the secret is that they lace it with heroin) and roasted garlic crab (which is made from a closely guarded family recipe –he allegedly turned down a million dollars for the recipe).

BEST Izakaya and Sake List: Izakaya Yuzuki -The sake sommelier there is incredibly knowl-edgeable and is a great guide to the world of sake. The food there is authentically Japanese, and I prefer it to the popular Nojo.

BEST Sushi: This is a tough one as my favorite sushi restaurants in the country are in NY, LA and even Boston, but worth visiting are Kiss and Ka-buto in SF, Hana in Rohnert Park, and Sushi Ran in Sausalito. I don’t think I want to give away ev-erything on this list, so if you really want the best sushi, I think I have to personally oversee the pro-ceedings and order very specific items.

BEST Dim Sum: Yank Sing – Some could argue Ton Kiang or even better, Koi Palace in Daly City, and I wouldn’t put up a huge fight in this cate-gory. Others would say it is overpriced here, and the dim sum at City View is a better value, and again, I wouldn’t fight too hard. But no one would say the dim sum is not awesome here. When you are bringing beginners or out of towners, this is the place.

BEST Pasta Dish: Tube pasta with faux gras and black truffles at Acquerello – arguably the best pasta dish on the planet was the original tube pas-ta with a foie gras and black truffle sauce… with

the militant foie gras laws, this will suffice.

Under Best Pizza category, I don’t really want to have to defend my choices as there now is decent pizza to be had in San Francisco, which I would argue didn’t really exist a decade ago. From local favorites like Pizzetta 211 to Delfina Pizzeria to the ever crowded Mozzeria to my neighborhood’s Gialina’s or even Zero Zero, there are actually a number of very good pizza in the city now. Here is my current list (always changing):

BEST Neapolitan Pizza: Margherita Pizza at Una Pizza Napolitana – a true pizza Nazi, and one may have to wait, but one cannot deny the quality of the pizza.

BEST ‘New York Style’ Pizza: The New Yorker at Tony’s – my brother told me this has gone down a notch recently, but I love this pizza. The multiple ovens etc makes for a great selection. The to go window next door may be the way to-go if there is a huge wait.

BEST Street Pizza: Cheese slice at Arinelle’s – street pizza reminiscent of walking around in Man-hattan for a slice.

BEST Chicago Style Pizza: The classic meat stuffed pizza at Patxi’s - No it isn’t Gino’s East, or Giordano’s, but if you are hankerin’ for a slice of stuffed pizza, go for it at Patxi’s. I like the one in the Marina, but the location on Irving is pretty convenient for UCSF staff (and they deliver!). If you’re down on the peninsula, stop in at Windy City Pizza and BBQ in San Mateo. Not bad either.

BEST Asian Type Salad: The Bangkok at Crep-evine (Irving) – A favorite among UCSF types, the Bangkok makes even meat eaters like me order salad. The Mango Salad from Mandalay is a win-ner as well.

BEST Seafood Salad: Lobster salad at Gary Danko – what can I say? Fresh Maine lobster with avocado, shaved fennel and citrus with an acidic and tart and herbaceous mustard- tarragon vinai-grette…but then again, I should not really single

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out this dish. Just go to GD. Order anything on the menu – especially if someone else is treating!

BEST Fried Chicken: Buttermilk Fried chicken at Ad Hoc – herbaceous and delicious! Thomas Keller writes in his cookbook, Ad Hoc at Home: ‘If there is a better fried chicken, I have not had it.’ – at least TK is not lacking for confidence! – I have made his version at home several times and I have to begrudgingly agree. Pretty spectacular fried chicken. At my home, there is hot sauce and wildflower honey available to add on the side, but it doesn’t really need it. Just keep track of the on- line menu and once a month, on a Monday, go up to Yountville, and enjoy. P.S. During the summer months, they have it to go next door for a great picinic!

BEST Roast Chicken: Roasted Vinegar Chick-en at BarbersQ (Napa) – one of the better roast chicken dishes around! Order it ahead of time so you don’t have to wait.

BEST Chicken Wings: Dry fried dry chicken wings at San Tung – I am not sure what dry fried dry ac-tually means, but believe me, the sweet sauce is not dry. It is tasty and finger lickin’ good! Close to UCSF Parnassus and so popular. Don’t miss the dumplings!

BEST Chicken Pot Pie: Chicken Pot Pie at Chen-ery Park – (special on some Thursdays) a flaky crust, good filling, fresh chicken. Creamy sauce. What more can you want?

BEST Pork Chop: Pork chop at Chenery Park – a seasonal item – when they have it, they brine it and grill it. And not dry, but moist and succulent.

BEST BBQ: The Texas style Beef Rib at Baby Blues BBQ – a Fred Flinstone Brontosaurus ap-pearing cut of meat. Perfect texture and great sauces. There are other candidates, but this one is unique. Come to the Mission (of course) and have great BBQ in SF!

BEST Upscale BBQ: At Wexler’s order - BBQ scotch eggs (do not omit this dish) with Wexler’s

plate of pork or smoked short rib followed by bour-bon banana cream pie (dulce de leche, fleur de sel) – Take really good BBQ and crank it up to the next level and you get Wexler’s – a small joint downtown dishing out awesome food and best el-evated BBQ in the city.

BEST Seafood Pot Pie: Signature Lobster Pot Pie at Michael Mina – another incredibly rich, stick to your ribs pot pie carried over for over 20 years since Michael was at Aqua (circling back to the same space years later partnering again with Ron Siegel, aka Iron Chef beater). The best lob-ster dish in the country is the warm lobster roll at Neptune’s Oyster in the North End of Boston, but MM’s lobster pot pie is a can’t miss SF item.

BEST Lobster Bisque: Lobster Bisque at Park Tavern – if incredibly rich food is not your style, stay away from this luxurious, unctuous, over the top rich bisque at Park Tavern.

BEST Steak: Japanese A5 at Alexander’s – When they banned foie gras in California there was real Japanese A5 to take over. You think $120 is too much for three ounces of the most ridicu-lously well marbeled beef in the world ? Then by all means go for one of the more domestic cuts, like the perfectly acceptable and nice dry or wet aged Niman-Ranch steaks, or Snake river domes-tic F1s or even Australian Wagyu and leave these rich Japanese cuts to those of us in the know.

BEST Tasting Menu: French Laundry – What can I say? Thomas Keller rules. Benu has a great tasting menu, as does Meadowood, and Saison and even the inventive and quirky Coi. But no one in the SF Bay area bests TK. No ingredients re-peated. Every dish leaves you wanting more. Cel-ebrate the end of your residency with your parents in Yountville at the best restaurant in the United States. Make them pay.

In conclusion, this is a highly subjective, non-scientific and maybe even a little quirky list of my BEST EATS of San Francisco list. I am happy to discuss and argue over decent wine or sake, and add to the list if I see fit.

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Stephen KiyoiLibrary Director

The Project - Invitation

The Library at San Francisco General Hospital in-vites UCSF residents to participate in a small study to see whether Quora, an online, social Q&A plat-form, can help find answers to clinical questions.

The Problem

Research has shown that although clinicians have multiple questions in the course of a typical pa-tient encounter, many of these questions go unre-searched and unanswered. If an answer is pursued, providers often turn to colleagues for quick answers, rather than the established research literature, which providers feel to be too time consuming. (1, 2)

Previous AttemptsThere have been several failed attempts to address this problem by crowdsourcing clinical questions and medical evidence. Medpedia, a “Wikipedia of medi-cine” that only physicians and biomedical research-ers could edit, abruptly closed early in 2013, even though it had backing from prominent institutions, such as Harvard Medical School, Stanford School of Medicine, and The UC Berkeley School of Public Health. Smaller scale attempts in academic settings haven’t been more successful. In 2004, a team of researchers at the National Library of Medicine de-veloped and piloted the “Virtual Evidence Cart”, an open, online platform to enable clinicians to submit and answer questions, to minimal fanfare and use. (3) A team of physicians and researchers at UNC Chapel Hill created the Critical Appraisal Resource (CAR) as a teaching tool for medical residents. Al-though this tool was widely used by the residents – there were 625 clinical questions entered, and 1035 searches in the 10 month study period – CAR re-lied on mandatory curriculum integration, and didn’t expand beyond the program for UNC medical resi-dents. (4)

How We’re Different

We hypothesize that previous attempts to crowd-source clinical questions have failed primarily be-cause they have been limited to a specific group of people or a specific institution. By contrast, Quora is open to all, has a culture of expert based answers, and enables upvoting and downvoting of both ques-tions and answers for easier discovery of relevant content. Posting questions on Quora could gener-ate answers from a broad range of experts, and the most highly ranked answers can reach a large audi-ence of clinicians as well as the general public. Our plan is to collect your questions, post them to Quora, and solicit participation from librarians, physicians and researchers across the country. We are plan-ning to present our findings at the annual meeting of the Medical Library Association in May, 2014.

Please consider contributing your clinical question via this survey link: https://ucsf.co1.qualtrics.com/SE/?SID=SV_dcaWXoy8xeH3h3f 1. Cook DA, Sorensen KJ, Wilkinson JM, Berger RA. Barriers and decisions when answering clinical ques-tions at the point of care: a grounded theory study. JAMA internal medicine. 2013;173(21):1962-9.

2. Ely JW, Osheroff JA, Chambliss ML, Ebell MH, Rosenbaum ME. Answering physicians’ clinical questions: obstacles and potential solutions. Journal of the American Medical Informatics Association : JAMIA. 2005;12(2):217-24.

3. Liu F, Fontelo P, Muin M, Ackerman M. Virtual Evi-dence Cart - RP (VEC-RP). AMIA Annual Sympo-sium proceedings / AMIA Symposium AMIA Sympo-sium. 2005:1034.

4. Crowley SD, Owens TA, Schardt CM, Wardell SI, Peterson J, Garrison S, et al. A Web-based compen-dium of clinical questions and medical evidence to educate internal medicine residents. Academic med-icine : journal of the Association of American Medical Colleges. 2003;78(3):270-4.

SFGH Library - Can Clinical Questions be Crowdsourced?

UCSF School of MedicineGraduate Medical Education500 Parnassus Avenue, MU 250 EastSan Francisco CA, 94143

tel (415) 476-4562fax (415) 502-4166www.medschool.ucsf.edu/gme

Many thanks to the following contributors:

Spring 2014

The Residents Report

Editorial Staff:Robert BaronAndrea CunninghamAmy Day

Cover Photo:Jeffrey Lee, MDGastroenterologyClinical Fellow

Cover Photo by:Elisabeth Fall

GME CYPHER

GME Contacts

GME ConfidentialHelp Line:(415) 502-9400

Amy Day, MBADirector of GME(415) 514-0146daya@medsch.ucsf.edu

Robert Baron, MD, MSAssociate Dean, GME(415) 476-3414baron@medicine.ucsf.edu

The Fall/Winter 2013 Cypher Answer was:

A wonderful fact to reflect upon, that every human creature is constituted to be that profound secret and mystery to every other.

Charles Dickens

Instructions: The above is an encoded quote from a famous person. Solve the cypher by substituting letters. Send your answers to CunninghamA@medsch.ucsf.edu. Correct answers will be entered into a drawing to win a $50 gift card!

Congratulations to Pathology ResidentGabrielle Rizzuto, MD, PhD - our Fall/ Winter 2013 Winner!

EQAKQSQADCOQ IK D WAQDL QHQYQCL NR KJOOQKK; IR GNJ NCHG ZCNOZ HNCW QCNJWB DCF HNJF QCNJWB DL LBQ WDLQ GNJ DAQ KJAQ LN XDZQ JE KNYQMNFG. -BQCAG XDFKXNALB HNCWRQHHNX

Peter ClarkSusan ConradJamine ErgasSam HawgoodRyutaro HiroseDavid JablonsStephen KiyoiMary McGrathAmi ParekhSarah ParisSara PlettGlenn RosenbluthRene SalazarNilay SethiMichele ShieldsSandrijn van Schaik