The Late-Night Teaching Files of ZSFG: Resident Initiative to Improve Education Tools

When the Emergency Radiology (ER) division launched in July 2022, implementing attending call coverage from 5 pm to midnight at Zuckerburg San Francisco General Hospital (ZSFG), this required changes to the education program to ensure that resident training offered both high quality instruction and autonomy. Two residents, Yannan Yu, MD, (’26) and Alice Zhou, MD, (’25) designed a system to use existing resources that the prior independent call system had provided through overnight primary case reads by a senior resident, then a review and final read by a junior resident with their attendings the next day.

Yu and Zhou noticed that the increased overnight efficiency eliminated some education opportunities for residents. Prior to the establishment of the ER/Acute Care division, senior residents staffed the overnight shifts at ZSFG as part of UCSF’s independent call structure. The ER division succeeded in vastly reducing the volume of studies remaining in the queue each morning. But that left first-year residents with fewer real-life examples to observe and learn from.

As Yu explained, “Attendings being there at night increases safety and efficacy, but we lose some learning the next day. We have to thoughtfully balance clinical quality and education.”

Yu and Zhou knew the benefit of having junior residents read overnight studies with attendings, illustrating and discussing pathologies that are less common during daytime imaging that tends to be more routine. This training alongside attendings is valuable for call preparation, so there had to be another way to ensure that residents could see the variety of emergency cases that the overnight shift encountered.

Zhou said, “As the ER division began its work, the list of overnight studies shrunk by over 50%. By simple chance, I did not get to see any MRs for appendicitis during my entire pediatrics rotation, all three years. My first time performing a reading was when I was on call.”

Yu and Zhou realized that ZSFG’s existing Teaching File database could help restore those morning educational moments. The ZSFG Teaching File is integrated with PACs and enables imaging studies to be saved in an anonymized format, stripped of all protected health info, for education use. Yu and Zhou, as part of the REFLECT program, a UCSF-wide fund to get residents involved in quality improvement efforts, pitched reinvigorating this underused system to address the changes brought by the ER division. The department was quick to support Yu and Zhou’s idea.

Now, ER attendings can save good teaching cases to an overnight conference list. Daytime residents then review these cases and save them to the ZSFG Teaching File to create a repository of cases for all residents to benefit from. That could be a very classic presentation of a common condition, or it could be a rare manifestation that a resident might not otherwise see. Over the last year more than 200 cases were saved to the teaching file, an effort the department has supported by providing a financial incentive. Approximately 20 cases are saved to the Teaching File every month, which are reviewed monthly at the Interesting Case Conference, a trainee-led program attended by all radiologists at ZSFG every Friday afternoon.

Zhou said, “The teaching file represents the apprenticeship way of learning that radiology often has. I appreciated that the department was very willing to make changes to the curriculum, to support the ongoing learning and the experience of residents. It gave me confidence in the way that we learn in this residency program.”

Call Prep Tool

Yu and Zhou worked with chief resident Stephen Wahlig, MD, to design a tool for first-year residents to check their knowledge of common conditions using the ZSFG teaching files. These “call prep quizzes” had specific learning objectives for each modality rotation, showing the residents common images in on-call shifts, with checkpoints each quarter.

Rather than cherry-picked slides in a textbook, the quiz simulates the full reading pattern and allows residents to practice making a full report. Over the first year of this system, the residency class demonstrated a 25% increase in their quiz scores corresponding to improved call preparedness.

Zhou noted, “There has been a very good response. Though we probably shouldn’t have called them quizzes! That made the first-year residents a little nervous.”