St. Joseph’s Family Medicine Curriculum
Family Medicine Adult Inpatient – The Family Medicine Adult Inpatient service is an opportunity to develop robust understanding and proficiency in the management of hospitalized adult patients. On-the Inpatient service, we care for patients that are directly admitted from our SJMC Emergency Department. We have two family Medicine teaching teams that work in collaboration with three Internal Medicine teaching teams through a solid Drip System structure that preserves resident admissions and education. Each month, each Family Medicine Inpatient team is well staffed with an inpatient faculty, one senior resident, two interns, and two rotating medical students from Touro University of California. With the assistance of senior residents, interns learn to thoroughly examine and develop comprehensive care plans for their patients each day, with further instruction and guidance from our Attending Physicians. We care for a deeply complex patient population, where we see a full spectrum of cardiac patients from MI and CHF exacerbations to complex arrhythmias, along with acute CVAs, gastrointestinal emergencies, surgical emergencies, respiratory failure, DKA/HHS, malignancies, and the full range of patients admitted for sepsis management, to name a few. We are also home to a full-service Heart and Vascular Institute, with a fully operational cardiac catheterization suite equipped for a variety of cardiac interventions, and a Cardiothoracic service which performs CABG procedures in-house. SJMC is also home to an ever-growing Interventional Radiology service, which is at the forefront of implementing many of the minimally invasive procedures that our patients require. Residents confidently learn to manage these procedure-bound patients and when to utilize these resources. Finally, SJMC is equipped with four separate ICU divisions, to which many of our admissions require admission. Residents and Interns continue the care of their patients when admitted in the ICU, ultimately enhancing their learning of critical care. The environment is truly collaborative, where questions are welcome and answers are thoughtfully approached.
Night Float – Interns will have an opportunity to complete 2x2 weeks of Night Float annually in a team often consisting of at least 1-2 Family Medicine Residents and one fellow Internal Medicine Resident. The Night Float team is dedicated mainly to the admission of patients from the hours of 7pm to 7am. With the supervision of a senior Resident, each Intern is given the time to examine and formulate a plan for each admission they receive, which will then be discussed with the Night Attending. The team will be called upon to answer pages from the floors and attend Rapid Responses or Codes as per the discretion of the Night Attending. Residents will come to learn the true spirit of collaboration, and develop critical thinking and problem solving strategies, while working under the cover of nighttime.
Intensive Care Unit – Residents will complete a dedicated rotation in the Intensive Care Unit during their second year of training. SJMC is home to four distinct ICU areas, which further specialize in their own aspect of intensive care, including medical, respiratory, cardiac, and surgical units. Our Residents complete their training in the respiratory ICU, where they can be expected to closely manage care for patients in septic or cardiogenic shock, ARDS, DKA, gastrointestinal bleeding, BiPAP dependent patients, amongst many other potential conditions. Supplementary topics Residents will become knowledgeable in include ventilator management, tube feedings, acid-base disorders, and Palliative Care. Above all, Residents will have ample opportunity and supervision to complete several inpatient procedures, including placement of central venous catheters, arterial lines, lumbar punctures, chest tubes, and running real-time Code Blues. There is one full block of ICU, in second year.
Ambulatory Care Clinic – To enhance experience and expertise in continuity of care, Residents are provided with a dedicated block in Continuity Clinic to care for their own panel of patients, and walk-in patients who require the same day care. Two full days each week will be dedicated to patient care in the morning and afternoon. Also integrated are one dedicated day of Procedure Clinic, in which Residents will have the opportunity to directly perform common outpatient procedures under the supervision of an Attending Physician, followed by a half-day of follow up on post-procedural care for patients. Procedures can include a wide range of outpatient staples, including incision and drainage, suture and staple removal, IUD placement and removal, Nexplanon placement and removal, colposcopies, joint injections, Pap smears, and biopsies, to name a few. A dedicated core of full-time faculty is present daily to supervise, demonstrate, and aid Residents in the development of patient care plans. Our clinic is also extremely fortunate to possess a dedicated pair of ultrasound machines, which are available for use in point-of-care ultrasound diagnoses for patients in the clinic. Overall, Residents will have four blocks of ACC experience. Residents will also have the opportunity for one block of dedicated Procedure Clinic in their third year of training.
Continuity Clinic – Outside of the dedicated Ambulatory Care rotation, our program consists of a weekly Continuity Clinic throughout the year, composed of half days of clinic per week, where we care for our own individual panel of patients. Our Interns will start with a smaller dedicated panel of their own patients, which will slowly increase in each year of Residency. Residents will be able to provide continuous care for these same patients throughout all three years of training, even as they continue to build their panel. Community Medical Centers (CMC) serves as the partnering institution where SJMC Residents complete their ambulatory outpatient training over three years. Community Medical Centers operates as a Federally Qualified Health Center which provides accessible care for all patients, including those without health insurance.
Research – Residents at SJMC are highly encouraged to participate in scholarly activities as the opportunities arise. And opportunities are indeed plentiful with respect to the acuity and complexity of the population served at SJMC. Our hospital library is equipped with an extensive digital catalog of journals, articles and research materials, and our hospital librarian is also skilled in aiding residents in finding applicable research resources. Residents also work directly alongside our Research director to recruit volunteers, obtain IRB review, and attendings’ support, or any other needs as they arise in the process. It is a requirement for a Family Medicine resident to work on a minimum of two scholarly activities during their residency training with one to be a Quality Improvement project.
Pediatrics Inpatient – The Pediatric Inpatient service is an opportunity for Residents to fully dedicate themselves to the care of our youngest population, from birth to the age of seventeen. Admitted Pediatric patients are cared for exclusively by the Family Medicine residents at SJMC, under the supervision of our Pediatric Inpatient Faculty. Patients can be admitted to the service from multiple venues, including the Emergency Department, outpatient PCP, transfers from neighboring hospitals, and in-house transfers from our on-site NICU. Each care team consists of a senior FM Resident, a FM Intern, and the supervising Pediatric Attending Physician. Each day consists of a structured format starting with teaching rounds at the bedside of each patient, followed by daily afternoon teaching sessions with the Attendings who share their expertise on interesting cases on the floor and other principles of Pediatric inpatient medicine. Residents will have broad exposure to a variety of conditions including anemia, hyperbilirubinemia, dehydration, asthma exacerbation, neonatal and pediatric sepsis, and a variety of other viral and bacterial diseases including gastrointestinal, cutaneous, genitourinary, and pulmonary infections. There are two Inpatient Pediatric medicine blocks, one in intern year and one in second year.
Pediatrics Ambulatory – The Ambulatory Pediatrics rotation is an opportunity to receive dedicated time and experience in the outpatient care of our neonatal and adolescent population. Residents receive direct daily experience with interviewing, examining and developing differentials to diagnose and treat pediatric aged patients, under the supervision of a Pediatrics trained Attending. With the cultural diversity and variety of backgrounds of the population in the Central Valley area, Residents quickly become comfortable providing culturally competent care for their pediatric patients, while addressing their needs from screenings, vaccinations, to provide effective acute care in the ambulatory setting. Residents also gain strong experience in learning how to triage patients who may need hospital admission, as opposed to those who may be treated outpatient. Above all, our supervising Pediatricians are committed to imparting management principles and pearls, in a collegial and comfortable environment, where learning is prioritized. There are two ambulatory Pediatric medicine blocks, one in intern year at CMC-Waterloo and one in third year at Woodland Clinic.
Newborn Nursery – Our residents work with pediatricians in the newborn nursery learning the general newborn physical examination. Residents gain experience in learning about screening tests and what to do with abnormal findings in newborns. This is a 2-week block rotation during the intern year.
Emergency Medicine – Our Residents join the Emergency Department during their second year of training to gain experience in managing patients at their first point of arrival to the hospital. Residents will participate in caring for patients at every level of acuity, including cases requiring immediate resuscitation to the urgent, and finally the non-urgent. Residents are strongly encouraged to triage patients at any acuity level that they wish to see, and are supervised by a dedicated Emergency Medicine Attending Physician in developing a care plan suitable for the patient, inclusive of procedures, treatment and potentially hospital admission. Residents are highly encouraged to perform their own procedures as necessary, including laceration repair, bedside incision and drainage, central venous catheter placement, intubations, and ultrasound guided paracentesis and thoracentesis. Family Residents work directly alongside Emergency Medicine Residents in an extremely collegial and collaborative space. There is one Emergency Medicine block, in the second year where Family Medicine Residents will be exposed to the Pediatric and Adult population.
Obstetrics – The SJMC Labor and Delivery unit is a newly built, fully modernized facility, where nearly 3000 babies are delivered annually. Our Family Medicine Residents have unopposed access to the entire unit to gain experience in delivering and managing laboring patients. Interns will have two dedicated blocks during their first year to directly perform vaginal and Cesarean deliveries with first-assist designation, under the supervision of our Obstetrics and Gynecology trained Attendings. Interns will have ample exposure and training in appropriately triaging, medically managing, then delivering vaginal patients, including performing perineal laceration repairs if necessary. Supplementary to delivering is gaining comprehensive experience in how to manage postpartum and antepartum patients. Our program is incredibly fortunate to have our own core faculty, Dr. Anuja Oza, who is both board certified in Family Medicine and Advanced Obstetrics Fellowship trained on-site during the week to further supervise and guide our Residents when they are on the floor with obstetric management. After the conclusion of the intern year, Residents will then go on to provide comprehensive prenatal care for their own dedicated prenatal patients in the Continuity Clinic and deliver the patient when the time comes. Overall, Interns will complete two blocks of obstetrics during their first year. Subsequently, Residents will then go on to care for their prenatal patients, including delivery and then postpartum care in the Clinic.
Cardiology – During their first year, Residents will join the Cardiology service to enhance their understanding of the range of the cardiac conditions that we care for both in the inpatient and outpatient setting. Residents will work directly under the supervision of the team of Interventional Cardiologists from the San Joaquin Cardiology Medical Group, all of whom are experts in their field. Each day, the team will participate in bedside rounds for patients consulted to the Cardiology service, followed by morning teaching and topical discussions on triaging, managing and following up on common cardiac conditions. Such topics can include atrial fibrillation, anticoagulation, myocardial infarction, CABG, CHF, CAD, hypertension, pericardial disease, and a variety of valvular abnormalities. In addition, EKGs are discussed daily in a dedicated workshop, designed to build progressively on interpretation skills with each session. Residents are welcome to perform in-house cardioversion for applicable patients, and directly observe procedures as desired for any patients who require cardiac intervention. There is a 2 week block of Cardiology in the first year as part of the curriculum and residents can choose cardiology as an elective block in their second and third year.
General Surgery – Residents will spend one month on service with the General Surgery team at SJMC. The surgical team is managed by the senior surgical residents of San Joaquin General Hospital, under the supervision of the SJMC General Surgery Attendings. Residents will gain experience in the pre and post-procedural management of surgical patients, and further understanding in the role of conservative versus invasive management. If residents choose to, they may join attendings in the OR to assist with surgical cases. There is a 2 week block of General Surgery, during intern year.
Gynecology – During the second year of training, Residents will join our Obstetrics and Gynecology Attending in the outpatient setting to further understand the guideline and evidenced-based practices for managing gynecological issues. Frequently encountered cases include breast and uterine malignancies, abnormal uterine bleeding, fertility, complex obstetrics care, and ambulatory procedures. Residents will also find that they will master the art of the Pap smear, IUD placements and removal, and competently perform colposcopies with biopsies. Gaining comfort and familiarity with the totality of care for female patients is the hallmark of this rotation. Residents will have the independence to formulate care plans, with guidance and supervision with each patient case. Residents are also welcome to join once weekly meditation sessions, if they wish to do so!
Geriatrics – During their second year of training, Residents will join our core Family Medicine faculty Dr. Shiraz Buhari and Dr. Rodney Deguzman, both of whom have extensive experience in art and practice of Geriatric Medicine, to learn the focus of care for our elderly population. Core issues of management include concerns for polypharmacy, pain management, end of life care discussions, appropriateness of screenings by age, and inpatient vs ambulatory management of infections in the elderly. Our Attendings have significant experience in various medical care models, and the variety of facilities in which care can be delivered in the outpatient setting for older adult patients. There is one block of Geriatrics in second year. Additionally, our Residents (if on outpatient services) have once a month visits to care for our own panel of patients admitted to a nearby Skilled Nursing Facility under the supervision of an additional Family Medicine trained faculty supervisor.
Behavioral Health/Psychiatry – Utilization of Behavioral Health interventions is increasing in Family Medicine practice, as depression, anxiety, and a variety of other behavioral and mental conditions increase in prevalence in the community. Our second-year Residents will rotate through our Behavioral Health service at a sister Community Medical Centers clinic, where they will understand the keys to analyzing behavior, motivational interviewing, and coping strategies for patients with recurrent behavioral patterns. Residents will also join our Psychiatry Attendings on the inpatient floors at SJMC to focus on understanding psychopharmacology, dosing and titration for hospitalized patients with comorbid psychiatric conditions.
POCUS/Radiology – During their second year of training, and preceding their Emergency Medicine block, Residents will complete a dedicated block of training designed to master the art of POCUS. Several members of our Emergency Medicine faculty are Fellowship trained in ultrasound. They are committed to training Residents in the art of using ultrasound to diagnose common conditions in the acute and ambulatory setting. Training directly alongside their fellow EM Residents, Residents will directly perform scans on patients and learn to interpret imaging in real-time. Commonly encountered diagnoses include aortic dissections, cholecystitis, abdominal aortic aneurysms, small bowel obstructions, abscesses and DVTs. Residents will also gain proficiency in the bedside echocardiogram and pleural effusions. In addition, during their time with the Interventional Radiology service, Residents will become proficient in performing ultrasound-guided paracentesis and thoracentesis, and interpreting basic radiographic images.
Surgical Subspecialties – During Intern year, our program offers a unique rotation dedicated to furthering experience in the subspecialties of Urology, Ophthalmology and Head and Neck Surgery. Conditions in these fields are commonly encountered by Family Medicine practitioners in everyday practice. Our Interns will be working under the supervision of Dr. Neal, Dr. Lee and Dr. Zhang for Urology from Touro University Medical Group directly adjacent to the hospital, where they will receive significant exposure on the management of many common urological conditions, including BPH, incontinence, complex dysuria, and malignancy. Subsequently, our Interns will then join Central Valley Eye Medical Group in Stockton to further train in common optical conditions and emergencies. Finally, our residents will complete training in common conditions of the ear, nose, and throat with the Head and Neck Clinic at the San Joaquin General Hospital. There is one block of Surgical Subspecialty training, in intern year and 2 weeks block in third year.
Orthopedics/MSK – Residents gain experience in the comprehensive management of musculoskeletal, sport-related injuries, and a wide range of other orthopedic conditions under the guidance of our Orthopedic Surgery Attendings at the Alpine Orthopedic Medical Group. Each day, Residents are assigned to work with a dedicated Orthopedic Surgeon, many of whom further specialize in specific joints, to fully understand the evaluation, physical exam and management of chronic and acute conditions. There are many opportunities to gain further experience in interpreting diagnostic imaging including plain radiographs and MRIs, learn the process of splinting and casting, and independently perform joint injections for eligible patients. During the block, Residents are invited to join their respective Attendings in the OR to assist with surgical cases. Additionally, Residents are welcome to join the Attendings of the Alpine Orthopedic Medical Group who provide care for the athletes of the University of the Pacific for their sports medicine needs, and act in the role of team physician on the sidelines for local high school sports games. There is one Orthopedic/MSK block, in intern year.
Pulmonology - On the Pulmonology service, Residents will be working directly with the SJMC ICU/Pulmonology physicians group and will be expected to learn about the wide spectrum of pulmonary diseases in both the inpatient and outpatient settings. In outpatient, Residents will focus on reading PFTs, how PFTs and spirometry are performed and followed over time, as well as how to work up and diagnose COPD, asthma, tuberculosis and other fungal lung diseases endemic to the region. Residents will develop in-depth knowledge of inhalers, active ingredients and indications for how they are administered. Inpatient Pulmonology will involve following patients who are hospitalized in the Respiratory ICU as well as receiving new consults around the hospital. Additionally, Residents will be required to take part in the ICU daily rounds with the interdisciplinary team. Overall, Residents will develop great insight in how respiratory diseases are managed in either setting.
Addiction Medicine - Our Family Medicine Residents will gain the knowledge, skills, and attitudes that are needed to care for patients with various substance use disorders including alcohol, OUD and other commonly used substances. Residents will be working in the Addiction Medicine clinic affiliated with Community Medical Centers and in St. Joseph's Behavioral Health. Residents will learn to obtain a focused biopsychosocial and substance use history, gain understanding of the various types of drugs commonly used in addiction, and become familiar with and use SBIRT (Screening, Brief Intervention, Referral to Treatment). In turn, this will enhance understanding of the different types of substance use disorder treatment options as they will better learn the neurobiology of substance use disorders. Finally, Residents will also gain experience in plans for pain management, and learn to manage substance use disorder patients with multiple comorbid medical and psychiatric disorders.
Practice Management - Practice Management focuses on providing our Residents with the knowledge to run their own Family Medicine clinics after graduating from residency. Two of our core program faculty members are the teaching Attendings who operate their own private clinic. Residents spend time away from clinical duties learning the fundamentals of operating a practice, and have ample opportunity to tailor the teaching to their professional goals after graduation. Additionally, our teaching faculty has extensive experience in the various models of Family Medicine practice after graduation, and are able to provide insight in these different areas to help guide Residents in their future goals. Learning is focused on the responsibilities a physician has in his or her clinic. Further, Residents can directly observe the teamwork needed between medical assistants, front desk staff, and the physician to ensure patients are taken care of and follow-ups are set appropriately.
Community Medicine - Our Residents will spend time in our community to allow them to become more aware of the disparities in access to healthcare in homeless communities, bridge gaps in healthcare, and learn what other resources are available to distribute care to an in-need population. Additionally, our program is affiliated with our local community high school, to help engage our young students in potential careers in healthcare and medicine. Further, our Residents engage in BUFA ( Black Urban Farmers Association) that helps impact health and hunger within our community. Finally, Residents will also be rotating through St. Mary’s Dining Room medical clinic, where they will become familiar with how to treat uninsured and homeless patients.
Dermatology - Our residents work with board certified dermatologists at Dignity Health Woodland Clinic. During this rotation, residents gain experience in learning about how care for patients with various skin disorders in the outpatient setting. This is a 2-week block rotation during the third year.
Electives - Electives allow residents the opportunity to tailor their educational training to fulfill their individual career plans. Available electives include Cardiology, Dermatology, Endocrinology, Gastroenterology, Infectious Disease, Nephrology, Hematology/ Oncology, Community Medicine, Neurology, Oncology, Sleep Medicine, Pulmonology, Rheumatology, Urology, Rural Medicine, Urgent Care, Global Health, Sports Medicine, Junior Faculty, OMT, Hospice and Palliative Care, ect... Residents see patients in various community clinics and in the private offices of these sub-specialists. Inpatient Rotations are often arranged at St. Joseph's Medical Center.