- Internal Medicine
Clinical Associate Professor, Medicine - Primary Care and Population Health
Honors & Awards
Excellence in Service Award (Medical Staff Awards), Stanford Health Care (2021)
Gold-Headed Cane Society Lecture, UCSF / Alpha Omega Alpha (2019)
"the one hundred" Honoree, Mass General Cancer Center (2017)
Caregiver Award, Addario Lung Cancer Foundation (2015)
Fellow (FACP), American College of Physicians (2013)
Community Service Award, UCSF Internal Medicine Residency Program (2010)
ACP Chapter Outstanding Associate Award, American College of Physicians, Northern California (2009)
Member, Alpha Omega Alpha (2007)
Board Certification: American Board of Internal Medicine, Internal Medicine (2022)
Fellowship: Stanford University Hospital -Clinical Excellence Research Center (2014) CA
Residency: UCSF Graduate Medical Education Office (2010) CA
Internship: UCSF Medical Center (2008) CA
Medical Education: Yale School Of Medicine (2007) CT
Community and International Work
Attending Physician, San Francisco Free Clinic, San Francisco, CA
San Francisco Free Clinic
Opportunities for Student Involvement
Honoring What We Say We Do: Developing Real-World Tools for Routine Family Caregiver Assessment and Support in Outpatient Palliative Care.
Journal of palliative medicine
Background: Family caregivers are essential to the care of patients with serious illness and supporting caregivers alongside patients is a core tenet of palliative care. While there is increasing recognition of the need to support family caregivers, there are limited resources to assess and support their needs in a systematic way in outpatient palliative care practice. Objectives: The aim of this study is to develop an approach to conducting assessments of routine needs and support of family caregivers in outpatient palliative care practice using a quality improvement framework. Setting: Seven, interdisciplinary, outpatient palliative care teams in California collaborated in this study. Measurements: Family caregivers were surveyed about levels of distress and support using a 10-point scale and asked about specific areas of need for support. Usefulness of a supportive caregiver resource was also measured on a 10-point scale, in addition to qualitative assessment of clinician satisfaction and feasibility of routine caregiver assessment and support. Results: Seven hundred thirty-six caregiver needs assessments were conducted and 44 supportive tool kits were distributed. A majority of family caregivers reported moderate or severe distress related to caregiving (score ≥4 on a 10-point scale). The most common sources of distress included emotional distress, worry caregiving was negatively impacting their own health, and planning for the future. Most caregivers reported feeling moderately or very well supported, most commonly by family, friends, and faith/spirituality. Caregivers rated the supportive tool kit an 8.4 on a 10-point usefulness scale and 92% would recommend it to others. Conclusions: We successfully developed and piloted practical clinical tools for routine family caregiver screening and support.
View details for DOI 10.1089/jpm.2022.0043
View details for PubMedID 36608316
Developing best practices for PPE Portraits across 25 sites: a systematic assessment ofimplementation and spread of adaptations using FRAME.
BMC health services research
2021; 21 (1): 1182
BACKGROUND: Adaptation, a form of modification that aims to improve an intervention's acceptability and sustainability in each context, is essential to successful implementation in some settings. Due to the COVID-19 pandemic, clinicians have rapidly adapted how they deliver patient care. PPE Portraits are a form of adaptation, whereby health workers affix a postcard size portrait of themselves to the front of their personal protective equipment (PPE) to foster human connection during COVID-19.METHODS: We used the expanded framework for reporting adaptations and modifications to evidence-based interventions (FRAME) method to better understand the reasoning behind and results of each adaptation. We hypothesized that using the FRAME in conjunction with design-thinking would lead to emerging best practices and that we would find adaptation similarities across sites. Throughout multiple implementations across 25 institutions, we piloted, tracked, and analyzed adaptations using FRAME and design thinking. For each adaptation, we assessed the stage of implementation, whether the change was planned, decision makers involved, level of delivery impacted, fidelity to original intervention, and the goal and reasoning for adaptation. We added three crucial components to the FRAME: original purpose of the adaptation, unintended consequences, and alternative adaptations.RESULTS: When implementing PPE Portraits across settings, from a local assisted living center's memory unit to a pediatric emergency department, several requests for adaptations arose during early development stages before implementation. Adaptations primarily related to (1) provider convenience and comfort, (2) patient populations, and (3) scale. Providers preferred smaller portraits and rounded (rather than square) laminated edges that could potentially injure a patient. Affixing the portrait with a magnet was rejected given the potential choking hazard the magnetic strip presented for children. Other adaptations, related to ease of dissemination, included slowing the process down during early development and providing buttons, which could be produced easily at scale.CONCLUSIONS: The FRAME was used to curate the reasoning for each adaptation and to inform future dissemination. We look forward to utilizing FRAME including our additions and design thinking, to build out a range of PPE Portrait best practices with accompanying costs and benefits.
View details for DOI 10.1186/s12913-021-06922-2
View details for PubMedID 34717597
- Better Health, Less Spending Delivery Innovation for Ischemic Cerebrovascular Disease STROKE 2014; 45 (10): 3105-?
Cost-saving innovations for acute ischemic stroke and transient ischemic attack.
Neurology. Clinical practice
2014; 4 (5): 427-434
Health care costs continue to rise toward unsustainable levels that will affect our nation's ability to support other key funding priorities for education, military, and infrastructure. Changing the way we deliver health care is critical to mitigating this financial crisis. This review highlights opportunities for redesigning care of acute ischemic stroke and TIA to maintain quality while substantially lowering costs. The recent innovations described are (1) adopting teleneurology networks to improve access to thrombolysis for acute ischemic stroke; (2) improving efficiency of emergency care for acute ischemic stroke; and (3) providing alternatives to inpatient care for TIA. Applying such process innovations will enable us to achieve the goal of patients and the nation-high-quality care at an affordable cost.
View details for DOI 10.1212/CPJ.0000000000000081
View details for PubMedID 29443219
View details for PubMedCentralID PMC5765688
- Better Health, Less Spending: Delivery Innovation for Ischemic Cerebrovascular Disease. Stroke; a journal of cerebral circulation 2014
What can be achieved by redesigning stroke care for a value-based world?
Expert review of pharmacoeconomics & outcomes research
Stroke results in significant healthcare costs and decreased quality of life. Thoughtful healthcare delivery redesign can help solve this problem through lower-cost, higher-quality care. The dominant fee-for-service reimbursement system may not incentivize delivery systems to invest in new cost-saving delivery innovations. Furthermore, lack of transparency hinder development of new systems of care. However, emerging payment models, including bundled payments and prospective payment, promote adoption of value-based stroke care methods. Both prevention and treatment of stroke offer opportunities to improve value-for-money via adoption of a package of emerging innovations. In order to encourage such adoption, alignment of incentives is crucial.
View details for DOI 10.1586/14737167.2014.946013
View details for PubMedID 25095813
The effect of a resident-led quality improvement project on improving communication between hospital-based and outpatient physicians.
American journal of medical quality
2013; 28 (6): 472-479
This article reports on a resident-led quality improvement program to improve communication between inpatient internal medicine residents and their patients' primary care physicians (PCPs). The program included education on care transitions, standardization of documentation, audit and feedback of documented PCP communication rates with public reporting of performance, rapid-cycle data analysis and improvement projects, and a financial incentive. At baseline, PCP communication was documented in 55% of patients; after implementation of the intervention, communication was documented in 89.3% (2477 of 2772) of discharges during the program period. The program was associated with a significant increase in referring PCP satisfaction with communication at hospital admission (baseline, 27.7% "satisfied" or "very satisfied"; postintervention, 58.2%; P < .01) but not at discharge (baseline, 14.9%; postintervention, 21.8%; P = .41). Residents cited the importance of PCP communication for patient care and audit and feedback of their performance as the principal drivers of their engagement in the project.
View details for DOI 10.1177/1062860613478976
View details for PubMedID 23526358
Intrauterine growth restriction and placental location
JOURNAL OF ULTRASOUND IN MEDICINE
2007; 26 (11): 1481-1489
The purpose of this study was to determine whether an association exists between intrauterine growth restriction (IUGR) and second-trimester placental location.A case-control study was performed in well-dated singleton pregnancies with (n = 67) and without (n = 205) IUGR (defined as estimated fetal weight <10th percentile for gestational age at the last sonographic examination) to investigate the association between IUGR and placental location. Placental location was determined by sonography at 16 to 20 weeks' gestation. Maternal, perinatal, and delivery characteristics were abstracted from medical records. Group comparisons were made by the Student t test, chi(2) analysis, the Fisher exact test, the Wilcoxon test, and analysis of variance. Multivariable logistic regression analysis was used to determine the relationship between IUGR and placental location.In both groups, the most common placental locations in the second trimester were anterior and posterior. After adjusting for potential confounders (including race, chronic hypertension, and hypertensive disorders of pregnancy), IUGR pregnancies were nearly 4-fold more likely to have lateral placentation (odds ratio, 3.8; 95% confidence interval, 1.3-11.2) compared with anterior or posterior placentation.Pregnancies complicated by IUGR are significantly more likely than non-IUGR pregnancies to have lateral placentation in the second trimester.
View details for Web of Science ID 000250639500003
View details for PubMedID 17957042
Bactericidal/permeability-increasing protein's signaling pathways and its retinal trophic and anti-angiogenic effects
2006; 20 (12): 2058-2067
Bactericidal/permeability-increasing protein (BPI) was originally identified as a lipopolysaccharide (LPS) binding protein with gram-negative bactericidal activity in the leukocytes. In this study, we characterized the previously unknown effects of BPI in the eye and the molecular mechanisms involved in its action. BPI mRNA was detected in bovine retina; retinal pigment epithelium; and primary cultures of bovine retinal pigment epithelial cells (RPE), pericytes (RPC), and endothelial cells (REC); while BPI protein was measured in human vitreous and plasma. BPI, but not control protein thaumatin, activated extracellular regulated kinase (ERK) and AKT, and increased DNA synthesis in RPE and RPC but not in REC. A human recombinant 21 kDa modified amino-terminal fragment of BPI (rBPI21) reduced H2O2-induced apoptosis in RPE and inhibited vascular endothelial growth factor (VEGF)-stimulated ERK phosphorylation in REC when preincubated with VEGF. Intraperitoneal (i.p.)-injected rBPI21 reduced ischemia-induced retinal neovascularization and diabetes-induced retinal permeability. Since BPI has unusual dual properties of promoting RPC and RPE growth while suppressing VEGF-induced REC growth and vascular permeability, the mechanistic understanding of BPI's action may provide novel therapeutic opportunities for diabetic retinopathy and age-related macular degeneration.
View details for DOI 10.1096/05-5662com
View details for Web of Science ID 000241156900014
View details for PubMedID 17012258
Hepatocyte growth factor induces retinal vascular permeability via MAP-kinase and PI-3 kinase without altering retinal hemodynamics
INVESTIGATIVE OPHTHALMOLOGY & VISUAL SCIENCE
2006; 47 (6): 2701-2708
Although vascular endothelial growth factor (VEGF) is a key mediator of retinal vascular permeability (RVP), there may be additional humoral contributors. Hepatocyte growth factor (HGF) induces endothelial cell separation, regulates expression of cell adhesion molecules and is increased in the vitreous fluid of patients with proliferative diabetic retinopathy. The purpose of this study was to evaluate the in vivo effects of HGF on RVP and retinal hemodynamics and delineate the signaling pathways.RVP was assessed by vitreous fluorescein fluorophotometry in rats. Time course and dose-response were determined after intravitreal HGF injection. MAP kinase (MAPK), phosphatidylinositol 3-kinase (PI-3 kinase), and protein kinase C (PKC) involvement were examined by using selective inhibitors. Retinal blood flow (RBF) and mean circulation time (MCT) were evaluated by video fluorescein angiography.HGF increased RVP in a time- and dose-dependent manner. HGF-induced RVP was evident 5 minutes after injection, and reached maximal levels after 25 minutes (+107% versus vehicle, P=0.002). This effect was comparable to that of maximum VEGF stimulation (134%+/-128% at 25 ng/mL). Selective inhibitors of MAPK (PD98059) and PI-3 kinase (LY294002) suppressed HGF-induced RVP by 86%+/-44% (P=0.015) and 97%+/-59% (P=0.021), respectively. Non-isoform-selective inhibition of PKC did not significantly decrease HGF-induced RVP. Although VEGF increases RBF and reduces MCT, HGF did not affect either.HGF increases RVP in a time- and dose-dependent manner at physiologically relevant concentrations with a magnitude and profile similar to that of VEGF, without affecting retinal hemodynamics. Thus, HGF may represent another clinically significant contributor to retinal edema distinct from the actions of VEGF.
View details for DOI 10.1167/iovs.05-0071
View details for Web of Science ID 000237949000059
View details for PubMedID 16723489