Clinical Assistant Professor, Pediatrics
Fellowship:Children's National Medical Center Pediatric Hospitalist Fellowship (2018) DC
Residency:Stanford University Pediatric Residency (2013) CA
Internship:Stanford University Pediatric Residency (2010) CA
Medical Education:Stanford University School of Medicine Registrar (2010) CA
Board Certification: Pediatrics, American Board of Pediatrics (2015)
- Promoting Shared Decision-Making Behaviors During Inpatient Rounds: A Multimodal Educational Intervention ACADEMIC MEDICINE 2019; 94 (7): 1010–18
Promoting Shared Decision-Making Behaviors During Inpatient Rounds: A Multimodal Educational Intervention.
Academic medicine : journal of the Association of American Medical Colleges
PURPOSE: To estimate the effectiveness of a multimodal educational intervention to increase use of shared decision-making (SDM) behaviors by inpatient pediatric and internal medicine hospitalists and trainees at teaching hospitals at Stanford University and the University of California, San Francisco.METHOD: The 8-week Patient Engagement Project Study intervention, delivered at 4 services between November 2014 and January 2015, included workshops, campaign messaging, report cards, and coaching. For 12-week pre- and postintervention periods, clinician peers used the 9-point Rochester Participatory Decision-Making Scale (RPAD) to evaluate rounding teams' SDM behaviors with patients during ward rounds. Eligible teams included a hospitalist and at least 1 trainee (resident, intern, medical student), in addition to nonphysicians. Random-effects models were used to estimate intervention effects based on RPAD scores that sum points on 9 SDM behaviors per patient encounter.RESULTS: In total, 527 patient encounters were scored during 175 rounds led by 49 hospitalists. Patient and team characteristics were similar across pre- and postintervention periods. Improvement was observed on all 9 SDM behaviors. Adjusted for the hierarchical study design and covariates, the mean RPAD score improvement was 1.68 points (95% CI, 1.33 to 2.03; P < .001; Cohen d = 0.82), with intervention effects ranging from 0.7 to 2.5 points per service. Improvements were associated with longer patient encounters and a higher percentage of trainees per team.CONCLUSIONS: The intervention increased behaviors supporting SDM during ward rounds on 4 independent services. The findings recommend use of clinician-focused interventions to promote SDM adoption in the inpatient setting.
View details for PubMedID 30893066
- Shared Decision-Making During Inpatient Rounds: Opportunities for Improvement in Patient Engagement and Communication JOURNAL OF HOSPITAL MEDICINE 2018; 13 (7): 453–61
Shared Decision-Making During Inpatient Rounds: Opportunities for Improvement in Patient Engagement and Communication.
Journal of hospital medicine
BACKGROUND: Shared decision-making (SDM) improves patient engagement and may improve outpatient health outcomes. Little is known about inpatient SDM.OBJECTIVE: To assess overall quality, provider behaviors, and contextual predictors of SDM during inpatient rounds on medicine and pediatrics hospitalist services.DESIGN: A 12-week, cross-sectional, single-blinded observational study of team SDM behaviors during rounds, followed by semistructured patient interviews.SETTING: Two large quaternary care academic medical centers.PARTICIPANTS: Thirty-five inpatient teams (18 medicine, 17 pediatrics) and 254 unique patient encounters (117 medicine, 137 pediatrics).INTERVENTION: Observational study.MEASUREMENTS: We used a 9-item Rochester Participatory Decision-Making Scale (RPAD) measured team-level SDM behaviors. Same-day interviews using a modified RPAD assessed patient perceptions of SDM.RESULTS: Characteristics associated with increased SDM in the multivariate analysis included the following: service, patient gender, timing of rounds during patient's hospital stay, and amount of time rounding per patient (P < .05). The most frequently observed behaviors across all services included explaining the clinical issue and matching medical language to the patient's level of understanding. The least frequently observed behaviors included checking understanding of the patient's point of view, examining barriers to follow-through, and asking if the patient has any questions. Patients and guardians had substantially higher ratings for SDM quality compared to peer observers (7.2 vs 4.4 out of 9).CONCLUSIONS: Important opportunities exist to improve inpatient SDM. Team size, number of learners, patient census, and type of decision being made did not affect SDM, suggesting that even large, busy services can perform SDM if properly trained.
View details for PubMedID 29401211
Patient Feedback Requirements for Medical Students: Do Perceived Risks Outweigh the Benefits?
2018; 57 (2): 193–99
Patient feedback has increasingly become part of medical students' training and formative assessment. We conducted a qualitative study using focus groups to explore students' experiences soliciting patient feedback, including the benefits, challenges, and potential strategies to obtain it. Fifteen medical students participated. Thematic analysis revealed students' (1) discomfort soliciting feedback and concern of being viewed as self-serving; (2) concerns about eroding patient trust; (3) indifference to nonspecific, positive feedback; and (4) belief that informally solicited feedback is most helpful for their learning. Strategies for soliciting more useful patient feedback included (1) team-based solicitation, (2) empowering patients as teachers, and (3) development of feedback instruments that allow patients to comment on specific student-identified learning goals. Solicitation of patient feedback is challenging for medical students and provokes discomfort. Strategies to integrate patient feedback into medical student training and assessment must attend to students' needs so the value of patient feedback can be realized.
View details for PubMedID 28952367
The SDM 3 Circle Model: A Literature Synthesis and Adaptation for Shared Decision Making in the Hospital.
Journal of hospital medicine
2017; 12 (12): 1001–8
Patient engagement through shared decision-making (SDM) is increasingly seen as a key component for patient safety, patient satisfaction, and quality of care. Current SDM models do not adequately account for medical and environmental contexts, which may influence medical decisions in the hospital. We identified leading SDM models and reviews to inductively construct a novel SDM model appropriate for the inpatient setting. A team of medicine and pediatric hospitalists reviewed the literature to integrate core SDM concepts and processes and iteratively constructed a synthesized draft model. We then solicited broad SDM expert feedback on the draft model for validation and further refinement. The SDM 3 Circle Model identifies 3 core categories of variables that dynamically interact within an "environmental frame." The resulting Venn diagram includes overlapping circles for (1) patient/family, (2) provider/team, and (3) medical context. The environmental frame includes all external, contextual factors that may influence any of the 3 circles. Existing multistep SDM process models were then rearticulated and contextualized to illustrate how a shared decision might be made. The SDM 3 Circle Model accounts for important environmental and contextual characteristics that vary across settings. The visual emphasis generated by each "circle" and by the environmental frame direct attention to often overlooked interactive forces and has the potential to more precisely define, promote, and improve SDM. This model provides a framework to develop interventions to improve quality and patient safety through SDM and patient engagement for hospitalists.
View details for PubMedID 29073314
Case 1: Acute-onset Vomiting, Fever, and Bulging Fontanelle in a 7-month-old Boy.
Pediatrics in review
2016; 37 (12): 536-538
View details for PubMedID 27909108
GOT SDM?: A MULTIMODAL INTERVENTION TO IMPROVE SHARED DECISION-MAKING DURING INPATIENT ROUNDS ON MEDICINE AND PEDIATRIC SERVICES
SPRINGER. 2016: S233–S234
View details for Web of Science ID 000392201600260
Case 1: Infant With Intrauterine Growth Restriction, Dehydration, and Weight Loss.
2015; 16 (12): e708-e710
View details for PubMedID 26705399
SHARED DECISION-MAKING DURING INPATIENT ROUNDS: DISSIMILAR YET CORRELATED PERSPECTIVES OF PATIENTS/GUARDIANS AND PHYSICIAN OBSERVERS
SPRINGER. 2015: S252
View details for Web of Science ID 000358386901079
SHARED DECISION MAKING DURING INPATIENT ROUNDS: OPPORTUNITIES FOR IMPROVEMENT IN PATIENT ENGAGEMENT AND COMMUNICATION
SPRINGER. 2015: S251
View details for Web of Science ID 000358386901078