CLINICAL AFFAIRS COMMITTEE
Warren Gold, M.D., Chair
Meeting of August 23, 2000
PRESENT: Warren Gold, Susan Janson, Richard Shafer,
ABSENT: Raymond Braham, Vice Chancellor Haile Debas, Joseph Guglielmo, Leslie Saxon, Scott Soifer, Joel White
GUESTS: Alan Gelb, Chief of Staff, Emergency Department, SFGH
Susan Carlisle, Chief, Anesthesia, SFGH
Kevin Grumbach, Chief, Family & Community Medicine, SFGH
Phil Hopewell, Associate Dean, SFGH
Talmage King, Chief, Department of Medicine, SFGH
Larry Pitts, Academic Senate Chair
The meeting of the Clinical Affairs Committee was called to order by Chair Gold on August 23, 2000 at 9:00 a.m. at San Francisco General Hospital. A quorum was present.
The minutes from July 26, 2000 were approved.
Announcement from Chair
Chair Gold announced that the Committee would produce an Academic Impact Report (AIR) to the Administration to address the financial crisis and other issues at San Francisco General Hospital (SFGH). This will be a means to gather information from those affected at SFGH.
Input from Alan Gelb
Dr. Gelb reported that no academic department of Emergency Medicine exists currently at UCSF and the staff has recently moved to the Department of Medicine.
Emergency Department at SFGH has been severely impacted by the loss of revenues and declining staffing levels. Due to overcrowding, 25% of ambulances (except for trauma cases) were turned away. As a result of these diversions, the education of students and housestaff and morale has been negatively impacted. Less housestaff are attracted to SFGH, therefore existing staff must contribute more work hours.
All faculty in the department are clinical faculty, but two-thirds of them conduct clinical research. Previously, clinical researchers were able to enroll many of their patients in studies but currently it is no longer safe to do so.
Because of diversions, hospital revenues are adversely decreased. Decreasing revenues causes hospital to decrease the number of beds, which causes more frequent diversions, which decreases revenues and a vicious cycle develops. Two-thirds of admissions come through the Emergency Department, therefore patients with strokes, heart attacks, pulmonary failure are being turned away and not available for teaching or clinical research.
The unsafe conditions at SFGH are more of a problem in nursing care. For example, cardiac patients are kept in the hall and monitored but no one is available to observe the monitors. Nurses are not trained to take care of patients as in-patients. Neurology patients are not observed every hour, as required. Some patients awaiting floor beds are kept waiting for 36 hours in the Emergency Room.
Previously, this rotation was the most popular fourth year rotation; now only 60 out of 150 students are enrolled and no one receives one-on-one mentoring.
Input from Susan Carlisle
Dr. Carlisle indicated that the Department of Anesthesia provides support for 8000 procedures per year, plus obstetrics, airway management and conscious sedation, including 22 out of the 52 weeks of coverage in ICU and oversight of Medical-Surgery of ICU. The department has 11.8 FTE’s funded with 16 clinically committed. Seven out of 16 are In-Residence faculty while the remaining are Clinical X or Clinical. All have active clinical research programs.
During the previous three days the Department placed three critically ill patients in the recovery area because of lack of beds. Therefore elective surgeries (usually from paying patients) have been cancelled. This overcrowded situation is unsafe for patients and nurses. Of the total 16 beds in the unit, all are currently filled, with fifteen of those beds occupied by patients on ventilators.
With respect to the residency program, 10 residents are assigned in the Operating Room and two are assigned in ICU. During congested periods, housestaff do not get appropriate operating experience. Residents must discharge patients from recovery room because general beds are full. This is occurring more frequently. Hospital Administration from the City indicated that this situation is temporary because positions were frozen, but this ignores the national nursing shortage, therefore the Department cannot recruit even for open positions. If the current situation continues in the Emergency Department, they will not be able to provide coverage and train residents properly.
Dr. Carlisle indicated that three to five medical students are assigned to the Operating Room at any one time. The congestion impacts their ability to receive an adequate educational experience.
Input from Kevin Grumbach
Dr. Grumbach indicated that the Family and Community Medicine is the only residency program in family medicine, with a large volume of medical students, nurse-practitioners, large in-patient service and ambulatory service. The department consists of 50 faculty, 39 residents, and numerous students from the Schools of Medicine, Pharmacy, and Nursing.
Dr. Grumbach reported that the largest impact of the funding crisis is on the in-patient service. The Department acts as in-patient service for all the City Public Health clinics. Diversion interrupts continuity of care. The Department does not have sufficient faculty to significantly increase training in the eight City clinics. The hiring freeze impacts students because there are not enough student slots to meet clinic demand. Any further faculty reductions will hurt their ability to teach students and house staff. Space and lack of clinical supervision contribute to this situation.
In the past year, the department experienced a 15% reduction in City funds for faculty this year. The City contracts for outpatient care and professional fees supply inpatient care. There is currently a freeze on all hiring plus there were 247 positions at all levels cut out of the budget in addition to the freeze on new hires or replacements.
Another impact of reduced funds is the inability for departments to admit patients therefore patients must reside in the Emergency Department many days until beds are available. Moffitt-Long Hospital has alternatives such as the Regents to provide financial support but SFGH has no such safety net. If funds are reduced, the staff or programs stay cut but no programs have been eliminated yet. As a result, many programs exist at bare bones level.
Input from Talmadge King
Dr. King reported that the Department of Medicine is a very large department that grew on the backs of faculty who obtained extramural funding. Two-thirds of the faculty providing attending supervision of students and housestaff and clinic services fund themselves on grants. The clinical programs depend on the City and professional fees and both have been declining. The Department has been most affected by the failure of professional fees to match increased costs.
Dr. King cited an upcoming total department deficit of $2.4 million, of which $700, 000 is due to reductions by the City; the remaining amount is due to inadequate professional fee income. The total clinical budget is $18 million. The City requested budget reductions, which the Department has attempted to follow. The Department decided to place more faculty on soft money. These faculty members continue clinical responsibilities, though the City does not pay for their services. They must continue in their labs and provide patient care.
Dr. King indicated that each program was reviewed and these major programs would be affected:
- Cardiology – care is rationed so that second class service is being provided. Some patients are evolving myocardial infarcts sitting in hallways. These reductions result in slower progress.
- Gastroenterology – shift from RN-based clinical service to LVN service. This shift means physicians must provide their own preparation and recovery services, which slows them down. A proposal has been offered to eliminate the nurse practitioner who had provided screening surveillance sigmoidoscopy. The City provides 0.75 FTE but 3.75 FTE’s are required to run the current GI unit.
- Pulmonary Medicine – This department operates the ICU and consultation service on the backs of the faculty scientists who are funded by grants. Professional fees do not adequately support faculty so scientists come out of their labs, supported by grants, to care for patients.
- Infectious Disease – department clinic has closed. This affected the Emergency Department’s ability to refer patients to this department. As a result, a follow-up option is no longer possible.
Dr. Pitts suggested another way of viewing the current situation. The City and County of San Francisco do not provide funds for research; furthermore, the City and County receive a significant percentage of its clinical care from faculty with dual roles. In effect, extramural research funds are supporting clinical care.
Dr. King indicated that junior faculty salaries at SFGH are not equal to junior faculty salaries at Moffitt-Long Hospital. He cites a gap between $20,000 to $30,000.
Dr. Gelb suggested that the Committee focus on the risk management issues when creating the Academic Impact Report.
- Inform Chancellor Bishop of educational impact from SFGH’s crisis
- Initiate Academic Impact Report
- Obtain reports from Drs. Hopewell and Grumbach
- Inform Regents of faculty concerns of reduction in quality of education
- Educate media on key issues
- Inform Michael Drake, Vice President for Health Affairs, UCOP
- Inquire with the four Deans their assessment of impact of SFGH crisis on their programs
- Inform Senators Boxer and Feinstein
The next meeting will take place on September 27 from 9:00 a.m. to 10:30 in M-688.
The meeting was adjourned at 10:30 a.m.