COMMUNITY-BASED ACADEMIC FACULTY PRACTICE  
UCSF Family Medicine Center at Lakeshore
 

San Francisco, California
Primary Contact: Albert Yu, MD, MPH, MBA
Age: 42
Years in Practice: 13 years
Medical School: State University of New York at Stony Brook
Residency: University of California, San Francisco

The Family Medicine Center at Lakeshore is a community-based academic faculty practice in the UCSF Department of Family and Community Medicine. It serves as a primary training site for 36 third-year medical students per year. This clinic was founded in 1994 and is located off campus in southwestern San Francisco. It serves a diverse community of patients from a broad range of ethnic, socioeconomic, and educational backgrounds, and accepts most types of insurance, including Medicare and Medi-Cal.

Faculty precept students both individually and in groups during their six-week experience. All students have the opportunity to receive more feedback on their clinical progress through review of videotaped clinical sessions with one of their preceptors. Each student completes a home visit with a patient selected by one of their preceptors and participates in an ongoing community project designed by faculty physicians to extend the reach of Lakeshore beyond the walls of the clinic. The Lakeshore practice is the most highly sought and highly-rated site for the third-year family medicine experience at UCSF. As one student describes the experience, "When I came to Lakeshore I had no aversion or affinity to family medicine, but I became very excited about it. It was powerful to work with three generations of a family and learn more about the family dynamics that may affect their health."

Lakeshore is also the site of a variety of clinical research projects, usually focusing on innovations to improve the quality of primary care. For example, in the last two years the practice has participated in studies designed to improve medication adherence for Type 2 diabetes, to improve the identification and treatment of depression, and to improve patient behaviors related to cardiovascular health.

Most faculty physicians have other roles outside of their clinical practice. Dr. Yu is Vice Chair of the Department of Family and Community Medicine and participates in a wide range of other professional activities. Several Lakeshore physicians participate in teaching at the UCSF Family Medicine Residency Program at San Francisco General Hospital, and others serve as medical student advisors or as coordinators of other parts of the medical school curriculum. Several are active volunteers in their local communities and in professional organizations or serve as medical editors for leading journals in the field of family medicine.

The mission of Lakeshore is to serve as a model family medicine practice, providing an opportunity to demonstrate and teach the full scope of family medicine to UCSF medical students, and to serve as a primary practice site for UCSF family medicine faculty physicians. It is a place where faculty of diverse interests can pursue rewarding clinical practices, serve as teachers and mentors to students, participate in meaningful clinical research, and provide outstanding service to their local communities. Lakeshore faculty physicians strive to:

• Meet the needs of patients in a holistic context recognizing their important relationships and their communities;
• Develop innovative and quality undergraduate medical curricula in family medicine;
• Transform clinical practice into a laboratory to study primary care innovations and office-based research; and,
• Provide valuable services to the community outside the clinical office.

Associate Clinical Professor Dr. Potter notes, "We strive to be a model family medicine site so medical students can see that with us, mission is first, and we offer the full range of practice." Faculty physicians treasure teaching medical students and residents about the values, practices and joy in family medicine. They model how long term relationships with patients and their families help diagnose and treat health problems. "We believe in the values of family medicine. Not just diagnosing and treating conditions, but helping patients stay healthy," says Dr. Strelkoff.

Since most clinical education is based in the hospital while the majority of care is provided in outpatient settings, the ambulatory family medicine rotation is critical in medical education. "Since the medical school works within a specialty-driven model, medical students have a unique opportunity to learn how family, culture, and community improve the care family physicians provide," explains Dr. Chin. The students agree. As one says, "This is the only place where I can have these conversations with patients." Jason Cheng, a third-year student says, "I liked to see patient progress and improvement over several visits, and I liked the diversity in patients and their medical problems. Overall it was a pretty awesome experience. Plus, the clinic was actually designed to involve medical students so there was plenty of time to debrief after each patient and discuss patient management and their clinical history."

As the only non-safety net family medicine group in the city of San Francisco that offers a full range of family medi-cine including maternity care, the group delivers approximately 120 babies a year. The philosophy of the group is to create a partnership with pregnant mothers to provide personalized care that is of the highest quality. They provide women with the information needed to make informed choices, creating a birth plan that emphasizes the special needs and desires of the individual and family.

The patients at UCSF Lakeshore Family Medicine are ethnically, economically and educationally diverse. Many patients are first generation immigrants from Asia and Eastern Europe. The clinic also serves patients with develop mental delay who live in group homes and are conserved by the state. In addition, Lakeshore serves as a primary care medical home for many UCSF physicians, nurses, students, and staff and their families. About one in three patients live in the greater San Francisco Bay Area and travel up to two hours to receive primary care at the faculty practice. Both upper-middle class and very poor patients live within the five zip codes of its primary service area, accounting for about half the patients at the practice. In 2000 the neighborhood surrounding Lakeshore was 4% African American, 44% Asian Pacific Islander, 13% Hispanic, 3% mixed and 35% Caucasian.

The practice is easily accessible to patients via a bus line and a very ample parking lot. As noted by Adrienne Lewis, administrative supervisor: "We are located in a shopping center because we wanted to be conveniently located for patients; easy and free parking is a real commodity in San Francisco."

Practice Statistics

Twelve faculty physicians see patients at Lakeshore. Some are primarily clinician-teachers and see patients between five and seven half-day sessions per week. Others have administrative or research roles and see patients between two and five sessions per week. Two family medicine fellows also practice at Lakeshore two sessions per week. A family nurse practitioner and a registered nurse extend physician care by providing urgent care and medical advice. In addition, a UCSF psychologist and dermatologist, boarded in both Family Medicine and Dermatology provide specialty services on-site. A team of licensed vocational nurses assists these clinicians with phlebotomy, immunizations, electrocardiograms, patient education and other procedures to facilitate patient flow and patient care. One Lakeshore physician has recently initiated a clinical program to serve homebound developmentally-delayed patients with home visits every one to two months. Seven of the 12 faculty physicians and the nurse practitioner incorporate family-centered maternity and newborn care into their clinical practice, including approximately 120 deliveries per year. Lakeshore physicians do not manage high-risk pregnancy, nor do they perform assisted deliveries.

UCSF Lakeshore Family Medicine offers the following outpatient services:

• Full spectrum E+M services from newborns to older adults
• Prenatal services
• A variety of office procedures in dermatology, gynecology, and orthopedics
• Behavioral and mental health
• Dermatology
• EKGs
• Phlebotomy
• Urinalysis
• Nebulizer treatments
• IV resuscitations
• Microscopic diagnostic tests

Compensation and Benefits

Physician salary is based on an academic structure that applies to faculty across the entire University of California system. Depending on full- or part-time status, faculty physicians earn in the range of $100,000 to $150,000 annually, including obstetrics. Faculty benefits include:

• 24 working days of vacation/sick leave, one paid week of CME, two weeks of holidays
• Full medical, dental, and vision coverage for families
• Vested retirement contribution after five years
• Six weeks and two weeks of paid leave for new mother and father, respectively
• Full malpractice coverage with tail
• Annual $1,500 CME and travel fund
• Generous self-purchased life, disability, and legal insurance options

Hours/Practice Flexibility

The physicians at UCSF Lakeshore estimate that they work 60-70 hours per week. Several physicians appreciate the ability to work part-time even though they are cognizant of the financial tradeoffs of part-time work. Evening and weekend calls are one in seven, which most feel is manageable. Deliveries, postpartum and newborn nursery care represent their only on-call, hospital-based clinical responsibilities.

Employees

One of the advantages of university affiliation is the ability to attract and employ longer-term staff because of the generous benefits and ability to move from one university setting to another. Employees have access to an array of training classes and university-wide resources.

Balance

"Balance is essential among four interdependent aspects of life - family, professional, personal and community connections. Happiness requires daily practice of compassion and self-healing, and regular examination of one's purpose and relationships" says Dr. Yu.

Other physicians talk about the challenge to balance family and work demands. "I negotiate every day with my husband about when each of us is going to be home," says one physician.

The difficulty of finding day care and housing that is both affordable and convenient in San Francisco is a constant challenge, but as one physician in the practice said, "that is the price for living in such a beautiful city."

UCSF Lakeshore Family Medicine looks for the following qualifications in new faculty members:

• Superior clinical knowledge and acumen
• Demonstrated skills and interests in teaching residents and students
• Demonstrated leadership in administration, research, and/or education innovations
• Ability to work effectively in teams with ethnically diverse patients and staff

One of the key issues facing the surrounding communities is the need for more primary care physicians, particularly family physicians, who are culturally and linguistically competent in a number of languages. Targeted services for teens, seniors, immigrants and the uninsured are also inadequate. These needs were detected through a Community-Oriented Primary Care project implemented in the past two years.

Faculty physicians enjoy the intellectually stimulating environment of the practice, the students and their colleagues. Lakeshore offers monthly on-site continuing medical education by inviting nationally-recognized specialist faculty members to speak to the group. Physicians doing obstetrics meet bi-monthly to conduct patient-based practice inquiries. In addition the entire group holds bi-monthly retreats with the sole purpose of enhancing personal and professional growth. The resource-rich environment at UCSF provides faculty physicians with many opportunities to pursue rewarding academic careers.

Continuous quality improvement and care delivery innovations are essential processes in the practice. Lakeshore has implemented a number of quality improvement initiatives over the past few years that include individualized point-of-care reminders for preventive care and chronic care, annual influenza vaccination clinics, group visits, expanded access, patient registries, patient-focused groups on their experience at Lakeshore, an intra-office electronic communication system, and the creation of practice teams.

Faculty physicians also participate in numerous office-based research studies in a wide-range of capacities, from recruiting patients to serving as principal investigators. Projects largely center on quality improvement, practice redesign and chronic illness care. The Department of Family and Community Medicine also organizes the UCSF Collaborative Research Network, a 400-member network of family physicians and practices throughout northern California.

One Lakeshore faculty physician, Dr. Michael Potter, is the co-director of this network. Examples of recent studies conducted at Lakeshore include:

• A Robert Wood Johnson Foundation-funded study of primary care interventions to promote health behaviors among patients with cardiovascular disease risk factors.
• A study of improving the coordination of care for depressed patients, examining the link between primary care and mental health.
• A survey of family physicians in northern California about chronic pain management.
• A survey of patients and their preferences for weight management.

Lakeshore is configured into four teams-each team consists of several faculty physicians, two LVNs and two clerical assistant staff-in order to address patient needs in the most timely and appropriate manner. All three groups of personnel are integral to each team. As Dr. Yu relates, "We build our teams based on provider-patient profiles, linguistic proficiency, and desired physician schedules. Our intention is to have teams whose members can help problem-solve for patients with challenging medical problems and who can provide patients with a sense of connection and service continuity."

Relationships with Other Specialists

Lakeshore faculty physicians are uniformly positive about the care given by the specialists at UCSF. It is one of the premier biomedical research and health science education centers in the world. They feel there is a good understanding of primary care and the role family medicine faculty physicians play in the overall care of patients among UCSF specialists.

Relationships with Other Health Providers

UCSF has a nationally recognized Osher Center for Integrative Medicine, whose mission is to search for the most effective treatments for patients by combining both conventional and alternative approaches that address all aspects of health and wellness - biological, psychological, social and spiritual. Two of the department's faculty physicians work collaboratively with faculty and also see patients directly at the Osher Center.

Hospital Relationships

UCSF Medical Center is the only affiliated hospital.

Relationships with University/Other Educational Settings

All physicians are salaried faculty members and all staff members are paid employees of the medical center. As an academic institution the practice enjoys the benefits of a rigorous learning environment, as well as access to medical expertise and clinical trials.

Relationships with Medical Students and Residents

Student and resident teaching represents a core professional activity for all faculty physicians. They are specifically hired and promoted based on their clinical performance and teaching evaluations. Lakeshore serves as one of the three main San Francisco-based teaching sites for third-year family medicine clerkship students, hosting six students per block, totaling 36 students per year. Lakeshore is unique in that it is the only clinical practice in San Francisco (other than the Department's residency clinic situated in a safety-net system) that models comprehensive ambulatory care for patients across the life-cycle with a core group of clinicians providing obstetrics and newborn care.

The Ambulatory Family Medicine Clerkship

The ambulatory family medicine clerkship is a critical component of the UCSF undergraduate medical curriculum. Participating in the care of outpatients in the context of long-term patient-provider relationships gives students the unique opportunity to experience how family, culture, and community affect the care family physicians provide. Students experience this through two models of learning: an apprenticeship model where they work with a specific physician, and an interactive group learning model where three students see patients independently but present together, learning from each other and from faculty physicians.

In addition to clinical preceptorship, other unique curricular components of the Lakeshore family medicine clerkship include videotape direct observations, home visits, behavioral science seminars, and Community-Oriented Primary Care experiential learning.

Each student is videotaped interviewing a patient with complex medical issues. This teaching method facilitates direct observation of the student's history taking skills. Faculty physicians give students individualized feedback and explore their strengths and weaknesses in patient communication.

The home health visit provides an opportunity for students to gain additional insight into a patient's life and particularly how health, family, culture and financial status all affect a patient's physical and emotional well-being. The behavioral science seminar is another important component of the clerkship experience. Students attend weekly two-hour seminars to explore how socioeconomic, linguistic, cultural, emotional and community factors influence the health of patients.

Faculty physicians at Lakeshore also teach residents at the residency-based Family Health Center, in addition to working with obstetric residents on the labor and delivery unit. A number of faculty physicians also facilitate small group seminars for pre-clinical students and serve in several leadership capacities for the UCSF pre-clinical and clinical medical curriculum.

All physician and exam rooms at Lakeshore have access to the Internet, to a partial electronic health record, and to patient scheduling. Many faculty physicians use PDA devices to access relevant clinical information at the point of care. Over the next four years UCSF will implement a robust EHR system for ambulatory care that will be integrated with inpatient clinical information systems.

Patient Communication

Lakeshore, the Department of Family and Community Medicine, and the UCSF Medical Center have a website on which patients can access information about the practice, the faculty and available resources within UCSF. In addition Lakeshore has a Web-based intra-office electronic communication system to manage patient telephone requests. This system reduces errors, improves patient satisfaction, and enhances office efficiency.

Practice Management Technology

Many financial and operational processes at Lakeshore are managed through computerized systems. All financial, registration, scheduling and most billing are done electronically.

Practice Management

Lakeshore Family Medicine's management team consists of a medical director (MD), an associate medical director (AMD), an administrative director (AD) and a clerical supervisor. Financial performance is monitored monthly by the MD and AD, while the medical center handles annual budgeting. All steps within the revenue cycle are done internally at the practice and through a centralized billing unit.

Other Practice Resources

Centralized risk management and administration representatives handle all legal matters as well as audits. The medical center's human resource and labor relations department handles personnel issues. The only outsourced service is facility cleaning.

Governance/Physician Leadership

Lakeshore Family Medicine is one of three practices within the UCSF Department of Family and Community Medicine. Several faculty physicians play key leadership roles within the Department, the UCSF Medical Center and School of Medicine. Faculty physicians report directly to the AMD and MD, who report to the Department Chair. They, in cooperation with the AD, make day-to-day decisions about practice operations.

Marketing

Lakeshore Family Medicine targets no particular market segment. In general, word-of-mouth and the UCSF affiliation are the most effective marketing strategies. There is little competitive threat in the local market. In fact there is a shortage of primary care physicians in San Francisco.

Coverage/Relations with Payers

The percentage of the practice covered by various payers can be broken down as follows: Capitation: 53%; PPO: 32%; Medicare: 13%; Self pay/Medi-Cal: 2%.

Nature of Contracts

UCSF Medical Group negotiates contracts for the practice.

Reimbursement

UCSF is a state institution and, as such, Lakeshore accepts all patients regardless of payment ability.

 

Primary Contact:	Albert Yu, MD, MPH, MBA
	Associate Clinical Professor and Medical Director
	San Francisco, California

Wendy Buffett, MD, Assistant Clinical Professor, UCSF Family Medicine Center at Lakeshore, San Francisco, California

Christine Chai, RN, FNP, UCSF Family Medicine Center at Lakeshore, San Francisco, California

Jean Chin, MD, Assistant Clinical Professor, UCSF Family Medicine Center at Lakeshore, San Francisco, California

Clarissa Kripke, MD, Assistant Clinical Professor, UCSF Family Medicine Center at Lakeshore, San Francisco, California

Michael Potter, MD, Associate Clinical Professor, UCSF Family Medicine Center at Lakeshore, San Francisco, California

Jonathon Rodnick, MD, Professor, UCSF Family Medicine Center at Lakeshore, San Francisco, California

Susan Runyan, MD, MPH, Assistant Clinical Professor, UCSF Family Medicine Center at Lakeshore, San Francisco, California

Katherine Strelkoff, MD, Associate Clinical Professor and Associate Medical Director, UCSF Family Medicine Center at Lakeshore, San Francisco, California

Practice Staff:

• Adrienne Lewis, Administrative Supervisor, UCSF Family Medicine Center at Lakeshore, San Francisco, California
• Tamara H. Liang, RN, BSN, PHN, Administrative Director, UCSF Family Medicine Center at Lakeshore, San Francisco, California

Others contacted for this profile:

Jason Cheng, 3rd year medical student, University of California at San Francisco, San Francisco, California.

Other Resources:

• www.medschool.ucsf.edu
UCSF Family Medicine Center at Lakeshore (practice brochure)