California Pacific Currents 2003
Specialized Residencies in Ophthalmology, Radiation Oncology, and Psychiatry Foster Confidence and Competence
Allan Pont, MD, Susan Day, MD
California Pacific Medical Center’s residency programs offer newly trained physicians, fresh out of internships, a chance to learn the most up-to-date approaches to patient care in a professional and compassionate environment.
As in all residencies, of course, there is that challenging first year. But California Pacific residents typically report that the collegial atmosphere here makes year one far more tolerable. In the process, they learn the extent of their own resources and develop the confidence they’ll need to succeed in practice, whether they opt for internal medicine or a subspecialty.
A Family Feeling
“It’s stimulating, having young people here, challenging each other and the attending physicians,” comments Jodi Langsfeld, California Pacific’s Director of Medical Education. “Our physicians agree that it helps them keep up to speed in their fields. It also helps if they know the people who will be practicing in their community.”
California Pacific’s staff now includes more than 100 doctors who received their residency training here, Langsfeld says. “They know the attending physicians, the referring doctors, the specialists. It has a strong feeling of family, which is a wonderful thing.”
The ultimate beneficiaries are, of course, the patients themselves. According to Allan Pont, MD, Chair of California Pacific’s Department of Medicine, residents are in the hospital day and night, maintaining close contact with patients at a level impossible for busy attending physicians. “If a lab test comes back, the residents are right there to deal with it,” remarks Dr. Pont. “In internal medicine alone, nine of our residents may be present in the hospital on any given night.”
The Menu of Residencies and Fellowships
California Pacific offers residencies in ophthalmology, psychiatry, radiation oncology, and internal medicine. For those who have completed residencies and want further study in a specialty, California Pacific has fellowships in cardiology, gastroenterology (GI), pulmonology, ophthalmology, and orthopedic surgery. Langsfeld says, “Most of the fellowships take place in the hospital. GI fellows do a lot of endoscopy. Cardiac fellows spend a lot of time in the CCU (Cardiac Care Unit), dealing with intensive heart issues and performing angioplasties. Residents and fellows alike take advantage of the knowledge available from a diverse, dedicated, and largely volunteer faculty whose members both practice and teach.”
California Pacific’s ophthalmology program holds three of the most coveted residency spots on the West Coast. More than 400 individuals apply each year, according to Susan Day, MD, Program Director and Chair of the department. (For perspective, consider that only 700 applications are filed annually for all the ophthalmology residency positions in the country.) Dr. Day now serves as chair of the ophthalmology residency review committee of the Accreditation Council on Graduate Medical Education, the national governing body that reviews and accredits programs such as those at California Pacific.
Part of the program’s appeal lies in its faculty—roughly 75 board-certified ophthalmologists from virtually every subspecialty who bring expertise in glaucoma, retina, cataract, neuro-ophthalmology, cornea and refractive surgery, pediatric ophthalmology, ocular pathology, strabismus, and uveitis. Most maintain practices in San Francisco and perform their surgeries on a nearby California Pacific campus.
“The educational environment attracts a certain kind of physician,” Dr. Day says. “One who wants to continue to learn, to be around inquiring minds. It fosters a curiosity for research and helps make care better for tomorrow’s patients.”
Brilliance and Breadth
Several factors contribute to the program’s quality and reputation. “Number one: bright residents,” Dr. Day emphasizes. “The majority of our residents are AOA [Alpha Omega Alpha, the med-school equivalent of Phi Beta Kappa]. Number two is our committed faculty. Number three is our broad patient base. Number four is exposure to all different aspects of the field.”
Residents expand their clinical and demographic experience by spending a year and a half at California Pacific; then a year at Highland Hospital, a county facility in Oakland known for trauma care; and finally six months at Kaiser Hospital in San Francisco, where they encounter a classic HMO environment. “When residents finish the program, you want them to be able to pursue a career doing whatever they want to do,” Dr. Day remarks. “In the past 10 years our graduates have obtained their first or second choice of fellowships in virtually every subspecialty, and all have become board certified.”
Experience and Focus
“Extensive exposure to surgery contributes to this successful record,” Dr. Day continues. “One of the most important factors in the quality of an ophthalmology program is whether there is the patient base to support a sufficient surgical caseload, and this is where our program shines,” she explains. On average nationally, most residents complete their programs having performed no more than 100 cataract surgeries. For California Pacific’s ophthalmology chief residents, the number is roughly three times that.
Another crucial element is exposure to research. Second- and third-year residents must present a research project at the annual alumni day. The program also offers research fellowships for up to one year prior to the formal residency—often in conjunction with San Francisco’s prestigious Smith-Kettlewell Eye Research Institute—as well as post-residency fellowships.
The ultimate focus remains on those who receive care. “I think the biggest advantage for the patients is that there is such a desire on the residents’ part to make sure that every aspect of their needs is being met,” Dr. Day says. “You also have the backup of the attending physician, who offers not only thoroughness but the wisdom of multiple years in practice.”
For David Sami, MD, the program’s current chief resident, the choice to come here was easy. “This program has a lot of strengths,” he says. “The faculty is excellent and there’s a very collegial atmosphere. For every surgery you do, you have an attending physician there, which is really important—but isn’t the case everywhere.”
Dr. Sami remarks that as good as the program is, it’s getting better every year, partly because administrators pay attention to what the residents tell them. “The department heads have a true open-door policy. You can go in and discuss anything, and whenever we’ve brought a problem to them—about on-call arrangements, or whatever—it’s been corrected right away.”
The kicker is one that many residents express: “Of course,” Dr. Sami adds, “it doesn’t hurt to be in San Francisco, either.”
California Pacific’s four-year radiation oncology program accepts just one resident annually and includes training in all aspects of the field in-cluding radiation physics, radiobiology, and statistics, according to Daniel Glaubiger, MD, PhD, Department Chair and Program Director. Residents also participate in a classic didactic teaching program and rotate through other specialties that interact with radiation oncology, including otolaryngology, gynecologic oncology, medical oncology, pediatric oncology, pathology, and diagnostic radiology.
“It’s very positive, having the residents,” Dr. Glaubiger says. “They bring a fresh perspective in terms of patient care, in the questions they ask, and in the knowledge base they contribute.”
In order to gain experience with the broadest possible patient base, the residents also serve at St. Francis Memorial Hospital in San Francisco, Seton Medical Center in Daly City, and Sacramento Medical Center, where they do pediatric rotations. “They see a broad spectrum of patients, including those with genitourinary malignancies and thoracic malignancies such as lung cancer,” Dr. Glaubiger notes. “We’re starting a neuro-oncology conference now, since we’re seeing an increased number of brain tumor patients.”
Difficulty and Hope
Asked whether residents might find it difficult to adjust to what could conceivably be a grim line of work, Dr. Glaubiger responds, “Most of the time it’s not emotionally difficult because they’re dealing with all kinds of different patients.” This impression is reinforced by fifth-year resident Simon Ro, MD, who has been with the program in its recent transition to California Pacific from St. Mary’s Hospital. “Certainly we treat some very sick patients,” he acknowledges, “but I think that’s balanced by the other side. We are curing patients of their cancer, which is very gratifying. If all of my patients were dying, I don’t know if I could do this. But it balances out. There have been so many advances in our field that most of our patients do very well.”
Psychiatry residents at CPMC learn to integrate disparate aspects of an increasingly expansive field, in that modern psychiatric practice draws on both traditional psychotherapy and the evolving field of psychopharmacology. The four-year program takes four residents per year, so there are sixteen enrolled at any given time. “It’s a relatively small, mentorship-oriented program,” says David Goldberg, MD, Program Director. “The residents are of a very high quality, which gets the faculty excited. In some ways the residency program is the engine of the whole department.”
After the program hit a rocky stretch six years ago, incoming department chair Joe Walker, MD, resolved to return it to excellence and recruited Dr. Goldberg to help. Dr. Goldberg, who trained in psychiatry at Yale, became a career educator and training director at the University of Connecticut. He was also the executive director of the American Association of Directors of Psychiatric Residency Training for 12 years and is the incoming president of that organization. Acknowledging the Contribution of Psychotherapy “One of the characteristics of San Francisco—and of this program—is that psychotherapy remains a highly valued and rigorous aspect of the residency,” Dr. Goldberg explains. “We want to train psychiatrists to be sophisticated and competent in diagnosis and treatment of all major mental illness. That means expertise in both psychotherapy and psychopharmacology.” The latter approach, also known as biologic psychiatry, entails arriving at a diagnosis and then treating the patient primarily with pharmaceuticals. Economic forces as well as clinical and scientific advances have led to increasing emphasis on this approach, while in many programs psychotherapy has become a poor stepchild.
Not so at California Pacific. Here, for that matter, psychotherapy isn’t just for those who have insurance to cover it, or those who can afford to pay out of pocket if they don’t. The hospital maintains a low-fee clinic that serves the community and a psychology internship program, whose students share many classes with the psychiatry residents.
A Labor-Intensive Approach
Residents benefit from the mentorship approach Dr. Goldberg mentioned—including several hours a week of intensive individual supervision—and up to 10 hours a week of lectures later in the program. “Physicians do a lot of teaching at the bedside,” Dr. Goldberg explains. “You see patients together with the residents in an apprenticeship model, so you can discuss their care. We want to focus on competency in terms of professionalism, being a humane and compassionate physician, being an interdisciplinary collaborator, and being knowledgeable about recent advances in clinical science. It’s a very labor-intensive teaching enterprise.”
Dr. Goldberg notes that the department is increasingly integrated with other aspects of medicine at California Pacific. “We have an active consultation service and have been developing liaisons with other fields such as oncology and transplant services,” he explains. “When we make joint rounds with the oncologists, we’re there to look for things that can be done to help people facing serious or terminal illness. A lot of issues come up around depression, hopelessness, and anxiety. We want to help at both an individual and a programmatic level.”
Integrating Culture and Spirituality
At California Pacific, there is a growing emphasis on cross-cultural psychiatry and spirituality. Tracy Peng, MD, a third-year resident in the program, came here to study with psychiatrist Elisabeth Targ, MD. She had practiced under Dr. Targ’s supervision for roughly six months when Dr. Targ was diagnosed with a brain tumor and subsequently died.
To continue this important aspect of Dr. Targ’s work, Dr. Peng recently received a grant from the American Psychiatric Association (APA) to support further work in psychiatry and spirit-uality. Dr. Peng has made it a personal quest to continue the project left behind by Dr. Targ’s passing—an example of the initiative and dedication the program encourages. “The grant has given me the opportunity to do what I always wanted to do, which is to ensure that spirituality remains a component of the curriculum here,” Dr. Peng says. “It also gives me a chance to see how we can provide the best end-of-life care, both psychiatric and medical, to dying patients in a spiritually informed manner.”
Hearts and Minds
As Jodi Langsfeld observes, “these are smart kids,” which is something of an understatement. What does she want for them by the time they leave California Pacific’s programs? “To be able to give their patients competent, good care,” she says. “But more than that, to remember that these are people—mothers, brothers, sisters, children—individuals with fears and concerns. Medicine is not an exact science, but people will turn to them for an answer. We want our residents and fellows to walk out of here knowing that they’re good physicians—that they can do this.”