- Internal Medicine
- Medical Education
- Point of Care Ultrasound
- Global Health
Clinical Professor, Medicine
POM Q4 Lead, Stanford School of Medicine (2019 - Present)
Capstone Clerkship Co-Director, Stanford School of Medicine (2013 - Present)
Point of care ultrasound rotation director, Stanford Hospital and Clinics (2011 - Present)
Clerkship Directory Med 300 and 314, Stanford School of Medicine (2016 - Present)
B2 Unit Based Medical Director, Stanford Hospital and Clinics (2012 - Present)
Associate Clerkship Director for Med 300 and Med 314, Stanford School of Medicine (2009 - 2016)
Educators for Care, Stanford School of Medicine (2012 - Present)
Boards, Advisory Committees, Professional Organizations
Fellow, Center for Innovation in Global Health (2015 - Present)
Residency: Stanford University CAPS Postdoctoral Fellowship (2005) CA
Board Certification: American Board of Internal Medicine, Internal Medicine (2008)
Medical Education: University of Virginia (2005) VA
Rania Abdusamad, Teni Anbarchian, Winston Becker, Georgiana Burnside, Josh Carter, Cordelia Erickson-Davis, Tania Fabo, Bunmi Fariyike, Shannon Francis, Anna Goshua, Dylan Griswold, Vivian Hua, Lily Kim, Grace Li, Gaurav Luthria, Ana Montalvo Landivar, Taishi Nakase, Chelsea Nnebe, Jaspreet Pannu, Binisha Patel, Neal Patel, Samson Peter, Tyler Raclin, Karthik Ravi, Gabriela (Gaby) Ruiz Colon, Matthew Schoen, Shiv Sethi, Varun Shanker, Haniyah Shareef, Audrey Todd, Ved Topkar, Pavin Trinh, Alondra Valencia, William Wang, Adele Xu, Caroline Yao, Yi Zhang, Joanne Zhou
- Improving the physical exam: a new assessment and evaluation tool for physical examination skills. Diagnosis (Berlin, Germany) 2022
Point-of-Care Ultrasound Predicts Clinical Outcomes in Patients With COVID-19.
Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine
OBJECTIVES: Point-of-care ultrasound (POCUS) detects the pulmonary manifestations of COVID-19 and may predict patient outcomes.METHODS: We conducted a prospective cohort study at four hospitals from March 2020 to January 2021 to evaluate lung POCUS and clinical outcomes of COVID-19. Inclusion criteria included adult patients hospitalized for COVID-19 who received lung POCUS with a 12-zone protocol. Each image was interpreted by two reviewers blinded to clinical outcomes. Our primary outcome was the need for intensive care unit (ICU) admission versus no ICU admission. Secondary outcomes included intubation and supplemental oxygen usage.RESULTS: N=160 patients were included. Among critically ill patients, B-lines (94 vs 76%; P<.01) and consolidations (70 vs 46%; P<.01) were more common. For scans collected within 24hours of admission (N=101 patients), early B-lines (odds ratio [OR] 4.41 [95% confidence interval, CI: 1.71-14.30]; P<.01) or consolidations (OR 2.49 [95% CI: 1.35-4.86]; P<.01) were predictive of ICU admission. Early consolidations were associated with oxygen usage after discharge (OR 2.16 [95% CI: 1.01-4.70]; P=.047). Patients with a normal scan within 24hours of admission were less likely to require ICU admission (OR 0.28 [95% CI: 0.09-0.75]; P<.01) or supplemental oxygen (OR 0.26 [95% CI: 0.11-0.61]; P<.01). Ultrasound findings did not dynamically change over a 28-day scanning window after symptom onset.CONCLUSIONS: Lung POCUS findings detected within 24hours of admission may provide expedient risk stratification for important COVID-19 clinical outcomes, including future ICU admission or need for supplemental oxygen. Conversely, a normal scan within 24hours of admission appears protective. POCUS findings appeared stable over a 28-day scanning window, suggesting that these findings, regardless of their timing, may have clinical implications.
View details for DOI 10.1002/jum.15818
View details for PubMedID 34468039
Lung Ultrasound Findings in Patients Hospitalized With COVID-19.
Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine
OBJECTIVES: Lung ultrasound (LUS) can accurately diagnose several pulmonary diseases, including pneumothorax, effusion, and pneumonia. LUS may be useful in the diagnosis and management of COVID-19.METHODS: This study was conducted at two United States hospitals from 3/21/2020 to 6/01/2020. Our inclusion criteria included hospitalized adults with COVID-19 (based on symptomatology and a confirmatory RT-PCR for SARS-CoV-2) who received a LUS. Providers used a 12-zone LUS scanning protocol. The images were interpreted by the researchers based on a pre-developed consensus document. Patients were stratified by clinical deterioration (defined as either ICU admission, invasive mechanical ventilation, or death within 28days from the initial symptom onset) and time from symptom onset to their scan.RESULTS: N = 22 patients (N = 36 scans) were included. Eleven (50%) patients experienced clinical deterioration. Among N = 36 scans, only 3 (8%) were classified as normal. The remaining scans demonstrated B-lines (89%), consolidations (56%), pleural thickening (47%), and pleural effusion (11%). Scans from patients with clinical deterioration demonstrated higher percentages of bilateral consolidations (50 versus 15%; P = .033), anterior consolidations (47 versus 11%; P = .047), lateral consolidations (71 versus 29%; P = .030), pleural thickening (69 versus 30%; P = .045), but not B-lines (100 versus 80%; P = .11). Abnormal findings had similar prevalences between scans collected 0-6days and 14-28days from symptom onset.DISCUSSION: Certain LUS findings may be common in hospitalized COVID-19 patients, especially for those that experience clinical deterioration. These findings may occur anytime throughout the first 28days of illness. Future efforts should investigate the predictive utility of these findings on clinical outcomes.
View details for DOI 10.1002/jum.15683
View details for PubMedID 33665872
Interobserver agreement of lung ultrasound findings of COVID-19.
Journal of ultrasound in medicine : official journal of the American Institute of Ultrasound in Medicine
BACKGROUND: Lung ultrasound (LUS) has received considerable interest in the clinical evaluation of patients with COVID-19. Previously described LUS manifestations for COVID-19 include B-lines, consolidations, and pleural thickening. The interrater reliability (IRR) of these findings for COVID-19 is unknown.METHODS: This study was conducted between March and June 2020. Nine physicians (hospitalists: n = 4; emergency medicine: n = 5) from 3 medical centers independently evaluated n = 20 LUS scans (n = 180 independent observations) collected from patients with COVID-19, diagnosed via RT-PCR. These studies were randomly selected from an image database consisting of COVID-19 patients evaluated in the emergency department with portable ultrasound devices. Physicians were blinded to any patient information or previous LUS interpretation. Kappa values (kappa) were used to calculate IRR.RESULTS: There was substantial IRR on the following items: normal LUS scan (kappa = 0.79 [95% CI: 0.72-0.87]), presence of B-lines (kappa = 0.79 [95% CI: 0.72-0.87]), ≥3 B-lines observed (kappa = 0.72 [95% CI: 0.64-0.79]). Moderate IRR was observed for the presence of any consolidation (kappa = 0.57 [95% CI: 0.50-0.64]), subpleural consolidation (kappa = 0.49 [95% CI: 0.42-0.56]), and presence of effusion (kappa = 0.49 [95% CI: 0.41-0.56]). Fair IRR was observed for pleural thickening (kappa = 0.23 [95% CI: 0.15-0.30]).DISCUSSION: Many LUS manifestations for COVID-19 appear to have moderate to substantial IRR across providers from multiple specialties utilizing differing portable devices. The most reliable LUS findings with COVID-19 may include the presence/count of B-lines or determining if a scan is normal. Clinical protocols for LUS with COVID-19 may require additional observers for the confirmation of less reliable findings such as consolidations.
View details for DOI 10.1002/jum.15620
View details for PubMedID 33426734
- A Mixed Methods Approach to Understanding Curricular Impact of a Capstone Course on the Self-Efficacy of Fourth-Year Medical Students CUREUS 2020; 12 (8)
A Mixed Methods Approach to Understanding Curricular Impact of a Capstone Course on the Self-Efficacy of Fourth-Year Medical Students.
2020; 12 (8): e9537
Background Capstone, or bootcamp, courses have been shown to increase the knowledge, skills, and self-efficacy of students prior to starting intern year and have been recommended by the Alliance for Clinical Education (ACE) to be incorporated into the fourth-year medical school curricula. However, a paucity of research exists regarding the exploration of the student perspective on critical curricular content and teaching strategies in a capstone course. Self-efficacy, one's subjective task-specific judgment of capability, has served in the literature as a framework for capstone outcomes and is derived from four sources of experiences: practice, observation of others, feedback, and one's emotional reaction to difficult situations. Utilizing this framework, we aimed to evaluate the impact of our capstone curriculum on students' self-efficacy and to identify critical curricular content and teaching strategies that affected students' self-efficacy and their transition into residency. Methods We designed a mixed methods study of our institution's capstone course in May 2019. Students were invited to participate in the retrospective pre- and post- self-efficacy survey and focus group immediately after the capstone and in semi-structured interviews four months after they began the intern year. Themes were identified via qualitative analysis using inductive coding to allow participants' voices to guide code development and deductive analysis using codes derived from the self-efficacy framework. Results Nine enrolled students participated in the study (surveys n=8, focus group n=7, follow-up interview n=6). Students reported the capstone was a very valuable educational experience (median 4.5 [interquartile range, or IQR 4-5]), increased their preparedness for intern year (median 5 [IQR 4.25-5]) and increased self-efficacy in multiple domains. Qualitative analysis revealed the critical curricular elements that most impacted students' self-efficacy were practical and communication skills to which students previously had limited exposure, in particular managing acute clinical needs, overnight cross-cover pages, inpatient pharmacology, daily intern communication (handoffs, consults, consenting), and end-of-life communication (goals of care, code status, pronouncing death). While all four sources contributed to self-efficacy, students reported that instructor and peer feedback were fundamental to providing context and substance to their performance. Students preferred practice-based learning via high-fidelity simulation and small groups for familiar tasks (daily intern communication, overnight pages, pharmacology) and observation of peers for new tasks (end-of-life communication and acute clinical deterioration). Conclusions This is the first study describing students' perspectives on critical curricular content and teaching strategies for a capstone course derived from qualitative analysis. Practical and communication skills with previously limited clerkship exposure and task-specific learning strategies increased the students' self-efficacy. Constructive feedback provided an important source of self-efficacy for all tasks, augmenting the benefits of practice and observation. This data provides preliminary groundwork for future research as multi-institutional studies are necessary to better understand students' needs around the curriculum to address residency transition.
View details for DOI 10.7759/cureus.9537
View details for PubMedID 32905172
View details for PubMedCentralID PMC7465827
- The Road Back to the Bedside. JAMA 2020; 323 (17): 1672–73
Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel-Group Randomized Trial.
Journal of hospital medicine
2020; 15 (2): e1–e6
BACKGROUND: Little is known about how to effectively train residents with point-of-care ultrasonography (POCUS) despite increasing usage.OBJECTIVE: This study aimed to assess whether handheld ultrasound devices (HUDs), alongside a year-long lecture series, improved trainee image interpretation skills with POCUS.METHODS: Internal medicine intern physicians (N = 149) at a single academic institution from 2016 to 2018 participated in the study. The 2017 interns (n = 47) were randomized 1:1 to receive personal HUDs (n = 24) for patient care vs no-HUDs (n = 23). All 2017 interns received a repeated lecture series regarding cardiac, thoracic, and abdominal POCUS. Interns were assessed on their ability to interpret POCUS images of normal/abnormal findings. The primary outcome was the difference in end-of-the-year assessment scores between interns randomized to receive HUDs vs not. Secondary outcomes included trainee scores after repeating lectures and confidence with POCUS. Intern scores were also compared with historical (2016, N = 50) and contemporaneous (2018, N = 52) controls who received no lectures.RESULTS: Interns randomized to HUDs did not have significantly higher image interpretation scores (median HUD score: 0.84 vs no-HUD score: 0.84; P = .86). However, HUD interns felt more confident in their abilities. The 2017 cohort had higher scores (median 0.84), compared with the 2016 historical control (median 0.71; P = .001) and 2018 contemporaneous control (median 0.48; P < .001). Assessment scores improved after first-time exposure to the lecture series, while repeated lectures did not improve scores.CONCLUSIONS: Despite feeling more confident, personalized HUDs did not improve interns' POCUS-related knowledge or interpretive ability. Repeated lecture exposure without further opportunities for deliberate practice may not be beneficial for mastering POCUS.
View details for DOI 10.12788/jhm.3351
View details for PubMedID 32118565
- The physical examination, including point of care technology, is an important part of the diagnostic process and should be included in educational interventions to improve clinical reasoning DIAGNOSIS 2019; 6 (3): 299–300
- Evaluation of Trainee Competency with Point-of-Care Ultrasonography (POCUS): a Conceptual Framework and Review of Existing Assessments JOURNAL OF GENERAL INTERNAL MEDICINE 2019; 34 (6): 1025–31
- Laying Hands on the Unstable Patient: Bedside Diagnosis in Medical Emergencies. The American journal of medicine 2019
Evaluation of Trainee Competency with Point-of-Care Ultrasonography (POCUS): a Conceptual Framework and Review of Existing Assessments.
Journal of general internal medicine
Point-of-care ultrasonography (POCUS) has the potential to transform healthcare delivery through its diagnostic expediency. Trainee competency with POCUS is now mandated for emergency medicine through the Accreditation Council for Graduate Medical Education (ACGME), and its use is expanding into other medical specialties, including internal medicine. However, a key question remains: how does one define "competency" with this emerging technology? As our trainees become more acquainted with POCUS, it is vital to develop validated methodology for defining and measuring competency amongst inexperienced users. As a framework, the assessment of competency should include evaluations that assess the acquisition and application of POCUS-related knowledge, demonstration of technical skill (e.g., proper probe selection, positioning, and image optimization), and effective integration into routine clinical practice. These assessments can be performed across a variety of settings, including web-based applications, simulators, standardized patients, and real clinical encounters. Several validated assessments regarding POCUS competency have recently been developed, including the Rapid Assessment of Competency in Echocardiography (RACE) or the Assessment of Competency in Thoracic Sonography (ACTS). However, these assessments focus mainly on technical skill and do not expand upon other areas of this framework, which represents a growing need. In this review, we explore the different methodologies for evaluating competency with POCUS as well as discuss current progress in the field of measuring trainee knowledge and technical skill.
View details for PubMedID 30924088
How are medical students using the Electronic Health Record (EHR)?: An analysis of EHR use on an inpatient medicine rotation.
2019; 14 (8): e0221300
Physicians currently spend as much as half of their day in front of the computer. The Electronic Health Record (EHR) has been associated with declining bedside skills and physician burnout. Medical student EHR use has not been well studied or characterized. However, student responsibilities for EHR documentation will likely increase as the Centers for Medicare and Medicaid Services (CMS) most recent provisions now allow student notes for billing which will likely increase the role of medical student use of the EHR over time. To gain a better understanding of how medical students use the EHR at our institution, we retrospectively analyzed 6,692,994 EHR interactions from 49 third-year clerkship medical students and their supervising physicians assigned to the inpatient medicine ward rotation between June 25 2015 and June 24 2016 at a tertiary academic medical center. Medical students spent 4.42 hours (37%) of each day at the on the EHR and 35 minutes logging in from home. Improved understanding of student EHR-use and the effects on well-being warrants further attention, especially as EHR use increases with early trainees.
View details for DOI 10.1371/journal.pone.0221300
View details for PubMedID 31419265
SIMULATION FOR IDENTIFICATION OF KNOWLEDGE GAPS AMONG TRAINEES IN CRITICAL CARE SCENARIOS
LIPPINCOTT WILLIAMS & WILKINS. 2019
View details for Web of Science ID 000498593402086
The physical examination, including point of care technology, is an important part of the diagnostic process and should be included in educational interventions to improve clinical reasoning.
Diagnosis (Berlin, Germany)
View details for PubMedID 30375346
Price and the Evolution of the Physical Examination
2018; 3 (4): 351
View details for PubMedID 29490337
The Role of Technology in the Bedside Encounter.
The Medical clinics of North America
2018; 102 (3): 443–51
Technology has the potential to both distract and reconnect providers with their patients. The widespread adoption of electronic medical records in recent years pulls physicians away from time at the bedside. However, when used in conjunction with patients, technology has the potential to bring patients and physicians together. The increasing use of point-of-care ultrasound by physicians is changing the bedside encounter by allowing for real-time diagnosis with the treating physician. It is a powerful example of the way technology can be a force for refocusing on the bedside encounter.
View details for PubMedID 29650066
- Internal Medicine: Challenges and Opportunities for Expanding Use SOUTHERN MEDICAL JOURNAL 2016; 109 (12): 750-753
Point-of-Care Ultrasound in Internal Medicine: Challenges and Opportunities for Expanding Use.
Southern medical journal
2016; 109 (12): 750-753
View details for PubMedID 27911966
The Five-Minute Moment.
American journal of medicine
2016; 129 (8): 792-795
In today's hospital and clinic environment, the obstacles to bedside teaching both for faculty and trainees are considerable. As Electronic Health Records (EHR) systems become increasingly prevalent, trainees are spending more time performing patient care tasks from computer workstations, limiting opportunities to learn at the bedside. Physical examination skills are rarely emphasized and low confidence levels, especially in junior faculty, pose additional barriers to teaching the bedside exam.
View details for DOI 10.1016/j.amjmed.2016.02.020
View details for PubMedID 26972793
- Medical Students and the Electronic Health Record: 'An Epic Use of Time' AMERICAN JOURNAL OF MEDICINE 2014; 127 (9): 891-895
- Medical students and the electronic health record: 'an epic use of time'. American journal of medicine 2014; 127 (9): 891-895
A history of physical examination texts and the conception of bedside diagnosis.
Transactions of the American Clinical and Climatological Association
2011; 122: 290-311
View details for PubMedID 21686233
- The Physical Exam and Other Forms of Fiction JOURNAL OF GENERAL INTERNAL MEDICINE 2010; 25 (8): 756-757
- Learning bedside medicine. The virtual mentor : VM 2009; 11 (11): 900-903
Renal failure and rhabdomyolysis associated with sitagliptin and simvastatin use
2008; 25 (10): 1229-1230
Sitagliptin is a new oral glucose-lowering medication that acts via the incretin hormone system. The most common side-effects are headache and pharyngitis, and few serious adverse events were observed during clinical trials. Dose adjustment is recommended in renal insufficiency, but long-term safety experience is limited.We present a patient with chronic renal insufficiency who developed leg pain, weakness and tenderness after starting treatment with high-dose sitagliptin while on simvastatin. The patient had acute renal failure and rhabdomyolysis that resolved with cessation of sitagliptin, simvastatin, ezetimibe, diuretics and olmesartan. All drugs except sitagliptin, ezetimibe and simvastatin were resumed, and the patient was subsequently started on lovastatin without recurrence of rhabdomyolysis.High doses of sitagliptin may have worsened this patient's renal failure and precipitated rhabdomyolysis by increasing circulating levels of simvastatin. Given the high likelihood that sitagliptin will be co-administered with statins and renally active medications, further study of long-term safety of sitagliptin in renal sufficiency may be warranted.
View details for DOI 10.1111/j.1464-5491.2008.02536.x
View details for Web of Science ID 000259814600013
View details for PubMedID 19046202