Malathi Srinivasan

All Publications

• Effect of race on opioid drug overdose deaths in the United States: an observational cross-sectional study. British journal of anaesthesia Le, A. D., Li, Y., Zhu, A., Singh, J., Xu, J. Y., Srinivasan, M., Palaniappan, L. P., Long, J., Gross, E. R. 2022

  View details for DOI 10.1016/j.bja.2022.06.005

  View details for PubMedID 35787800

• Cardiovascular and Cerebrovascular Disease Mortality in Asian American Subgroups. Circulation. Cardiovascular quality and outcomes Shah, N. S., Xi, K., Kapphahn, K. I., Srinivasan, M., Au, T., Sathye, V., Vishal, V., Zhang, H., Palaniappan, L. P. 2022: 101161CIRCOUTCOMES121008651

  Abstract

  BACKGROUND: Asian American individuals comprise the fastest-growing race and ethnic group in the United States. Certain subgroups may be at disproportionately high cardiovascular risk. This analysis aimed to identify cardiovascular and cerebrovascular disease mortality trends in Asian American subgroups.METHODS: Age-standardized mortality rates (ASMR), average annual percent change of ASMR calculated by regression, and proportional mortality ratios of ischemic heart disease, heart failure, and cerebrovascular disease were calculated by sex in non-Hispanic Asian American subgroups (Chinese, Filipino, Asian Indian, Japanese, Korean, and Vietnamese), non-Hispanic White, and Hispanic individuals from US death certificates, 2003 to 2017.RESULTS: Among 618 004 non-Hispanic Asian American, 30 267 178 non-Hispanic White, and 2 292 257 Hispanic deaths from all causes, ASMR from ischemic heart disease significantly decreased in all subgroups of Asian American women and in non-Hispanic White and Hispanic women; significantly decreased in Chinese, Filipino, Japanese, and Korean men and non-Hispanic White and Hispanic men and remained stagnant in Asian Indian and Vietnamese men. The highest 2017 ASMR from ischemic heart disease among Asian American decedents was in Asian Indian women (77 per 100 000) and men (133 per 100 000). Heart failure ASMR remained stagnant in Chinese, Korean, and non-Hispanic White women, and Chinese and Vietnamese men. Heart failure ASMR significantly increased in both sexes in Filipino, Asian Indian, and Japanese individuals, Vietnamese women, and Korean men, with highest 2017 ASMR among Asian American subgroups in Asian Indian women (14 per 100 000) and Asian Indian men (15 per 100 000). Cerebrovascular disease ASMR decreased in Chinese, Filipino, and Japanese women and men between 2003 and 2017, and remained stagnant in Asian Indian, Korean, and Vietnamese women and men. The highest cerebrovascular disease ASMR among Asian American subgroups in 2017 was in Vietnamese women (46 per 100 000) and men (47 per 100 000).CONCLUSIONS: There was heterogeneity in cardiovascular and cerebrovascular mortality among Asian American subgroups, with stagnant or increasing mortality trends in several subgroups between 2003 and 2017.

  View details for DOI 10.1161/CIRCOUTCOMES.121.008651

  View details for PubMedID 35535589

• Acculturation and Associations with Ultra-processed Food Consumption among Asian Americans: NHANES, 2011-2018. The Journal of nutrition Pachipala, K., Shankar, V., Rezler, Z., Vittal, R., Ali, S. H., Srinivasan, M. S., Palaniappan, L., Yang, E., Juul, F., Elfassy, T. 2022

  Abstract

  BACKGROUND: Ultra-processed food (UPF) consumption is linked to adverse health outcomes, including cardiovascular disease and all-cause mortality. Asian Americans (AAs) are the fastest growing ethnic group in the United States (US), yet their dietary patterns have seldom been described.OBJECTIVES: To characterize UPF consumption among AAs and determine whether acculturation is associated with increased UPF consumption.DESIGN: The National Health and Nutrition Examination Survey (NHANES) is an annual, cross-sectional survey representative of the US population. We examined 2011-2018 NHANES data which included 2404 AAs≥18 years old with valid 24-hour dietary recall. Using day 1 dietary recall data, we characterized UPF consumption as the percentage of caloric intake from UPFs, using the NOVA classification system. Acculturation was characterized by nativity status, nativity status and years in the US combined, home language, and an acculturation index. We assessed the association between acculturation and UPF consumption using linear regression analyses adjusted for age, sex, marital status, education, income, self-reported health, and self-reported diet quality.RESULTS: UPFs provided on average 39.3% (95% CI: 38.1-40.5) of total energy intake among AAs. In adjusted regression analyses, UPF consumption was 14% (95% CI: 9.5-17.5; P<0.05) greater among those with the highest vs. lowest acculturation index score, 12% (95% CI: 8.5-14.7: P<0.05) greater among those who speak English only vs. non-English only in the home, 12% (95% CI: 8.6-14.7: P<0.05) greater among US-born vs. foreign-born AAs, and 15% (95% CI: 10.7-18.3: P<0.05) greater among US-born vs. foreign-born AAs with less than ten years in the US.CONCLUSIONS: UPF consumption was common among AAs, and acculturation was strongly associated with greater proportional UPF intake. As the US-born AA population continues to grow, UPF consumption in this group is likely to increase. Further research on disaggregated AA subgroups is warranted to inform culturally tailored dietary interventions.

  View details for DOI 10.1093/jn/nxac082

  View details for PubMedID 35389482

• Vaccination patterns, disparities, and policy among Asian-Americans and Asians living in the USA Jamal, A., Wang, R., Wang, Z., Dan, S., Srinivasan, M., Kim, G., Palaniappan, L., Singh, J., Kappagoda, S. ELSEVIER SCI LTD. 2022: 27

  View details for Web of Science ID 000779259700028

• Acculturation And Associations With Ultra-processed Food Consumption Among Asian Americans: NHANES, 2011-2018 Pachipala, K., Shankar, V., Rezler, Z., Vittal, R., Ali, S., Srinivasan, M., Palaniappan, L., Yang, E., Juul, F., Elfassy, T. LIPPINCOTT WILLIAMS & WILKINS. 2022

  View details for DOI 10.1161/circ.145.suppl_1.P210

  View details for Web of Science ID 000805839700407

• Vaccination patterns, disparities, and policy among Asian-Americans and Asians living in the USA. The Lancet. Global health Jamal, A., Wang, R., Wang, Z., Dan, S., Srinivasan, M., Kim, G., Palaniappan, L., Singh, J., Kappagoda, S. 2022; 10 Suppl 1: S27

  Abstract

  Although Asian-American individuals have higher rates of some vaccine-preventable diseases such as hepatitis B, vaccination rates among them are low compared with those of non-Hispanic White individuals. Most vaccine research looks at Asian-American people as a single category despite large within-group heterogeneity in health-seeking behaviours. Little is known about vaccination coverage among disaggregated Asian-American ethnic subgroups, although such information could inform policies focused on increasing vaccine uptake. Therefore, we aimed to assess vaccination coverage for several vaccines among disaggregated Asian-American subgroups.We examined National Health Interview Survey (NHIS) data from 2015-18 to analyse the vaccination status of Chinese, Asian Indian, Filipino, other Asian, and non-Hispanic White adults (n=253 626) for seven vaccines recommended by the US Centers for Disease Control and Prevention: human papillomavirus (HPV), hepatitis B (HBV), influenza, tetanus, tetanus-diphtheria-pertussis (Tdap), shingles, and the pneumococcal vaccine. We used NHIS data from 2006-18 (n=880 210) to analyse changes in vaccination rates for each ethnic group over time. We used logistic regression to estimate differences in vaccination rates while controlling for demographic, socioeconomic and health-related variables.Among the seven vaccines, HPV and shingles vaccines had the lowest uptake, whereas Tdap had the highest uptake among all groups. Compared with the non-Hispanic White group, Asian Indians were almost half as likely to receive the HPV vaccine (odds ratio 0·61, 95% CI 0·41-0·92), whereas Filipinos (1·51, 1·02-2·25) and other Asians (1·42, 1·02-1·97) were more likely to receive it. The Filipino (1·50, 1·21-1·88) and other Asian groups (1·42, 1·19-1·71) were more likely to receive the HBV vaccine than the non-Hispanic White group. For the influenza vaccine, the Asian Indian (1·28, 1·05-1·56), Filipino (1·44, 1·17-1·79) and other Asian (1·38, 1·16-1·65) groups were more likely to receive the vaccine than the non-Hispanic White group. For the pneumococcal vaccine, the Chinese (0·57, 0·34-0·94) and other Asian (0·66, 0·47-0·92) groups were less likely to receive the vaccine than the non-Hispanic White group.Among US adults, we found significant disparities in vaccine uptake among different Asian and Asian-American ethnic groups. US policy makers trying to improve vaccine uptake among Asian and Asian-American people could learn from successful international immunisation programmes to develop culturally appropriate interventions to improve vaccine uptake in Asian and Asian-American individuals.None.

  View details for DOI 10.1016/S2214-109X(22)00156-5

  View details for PubMedID 35362432

• Psychological Distress and Mental Health Service Utilization Disparities in Disaggregated Asian American Populations, 2006-2018 Asian American Journal of Psychology Balaraman, K. K., Dan, S., Ortega, N., Srinivasan, M., Joshi, S. V. 2022

  View details for DOI 10.1037/aap0000294

• Cancer Mortality in US-born vs. Foreign-born Asian American Groups (2008-2017). Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology Tripathi, O., He, Y., Han, B. Y., Paragas, D. G., Sharp, N., Dan, S., Srinivasan, M., Palaniappan, L. P., Thompson, C. A. 2021

  Abstract

  Background Asian Americans (AA) are the fastest growing ethnic group in the US with high proportions of immigrants. Nativity is important as cancer risk factors vary by country. We sought to understand differences in cancer mortality among AAs by nativity (foreign-born vs. US-born). Methods 98,826 AA (Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese) decedents with cancer-related deaths from US death certificates (2008-2017) were analyzed. Thirteen cancers that contribute significantly to AA cancer mortality were selected and categorized by etiology: tobacco-related, screen-detected, diet/obesity-related, and infection-related. 10-year age-adjusted mortality rates [AAMR (95% CI); per 100,00] and standardized mortality ratios [SMR (95% CI)] using foreign-born as the reference group were calculated. Results Overall, foreign-born AAs had higher mortality rates than US-born. Japanese US-born males had the highest tobacco-related mortality rates (Foreign-born AAMR: 43.02 [38.72, 47.31], US-born AAMR: 55.38 [53.05, 57.72]). Screen-detected death rates were higher for foreign-born than US-born, except for among Japanese males [SMR 1.28 (1.21-1.35)]. Diet/obesity-related AAMRs were higher among females than males and highest among foreign-born females. Foreign-born males and females had higher infection-related AAMRs than US-born; the highest rates were foreign-born males: Korean (AAMR 41.54 [39.54, 43.53]) and Vietnamese (AAMR 41.39 [39.68, 43.09]). Conclusions We observed substantial heterogeneity in mortality rates across AA groups and by nativity. Contrary to the Healthy Immigrant Effect, most foreign-born Asians were dying at higher rates than US-born AAs. Impact: Disaggregated analysis of AA cancers, targeted and culturally tailored cancer screening, and treatments for infections among foreign-born Asians is critical for cancer prevention efforts.

  View details for DOI 10.1158/1055-9965.EPI-21-0359

  View details for PubMedID 34697057

• When it's needed most: a blueprint for resident creative writing workshops during inpatient rotations. BMC medical education Edwards, L. M., Kim, Y., Stevenson, M., Johnson, T., Sharp, N., Reisman, A., Srinivasan, M. 2021; 21 (1): 535

  Abstract

  BACKGROUND: Narrative Medicine may mitigate physician burnout by increasing empathy and self-compassion, and by encouraging physicians to deeply connect with patient stories/experiences. However, Narrative Medicine has been difficult to implement on hectic inpatient teaching services that are often the most emotionally taxing for residents.OBJECTIVE: To evaluate programmatic and learner outcomes of a novel narrative medicine curriculum implementation during inpatient medicine rotations for medical residents. Programmatic outcomes included implementation lessons. Learner outcomes included preliminary understanding of impact on feelings ofburnout. Additionally, we developed a generalizable narrative medicine framework for program implementation across institutions.METHODS: We developed and implemented a monthly 45-min Narrative Medicine workshop on Stanford's busiest and emotionally-demanding inpatient rotation (medical oncology). Using the Physician Wellbeing Inventory (PWBI, range 1-7; 3-4=high burnout risk; ≥4, high burnout), we anonymously assessed resident burnout during pre-implementation control year (2017-2018, weeks 1and 4), and implementation year (2018-2019, weeks 1 and 4). We interviewed program directors and facilitators regarding curriculum implementation challenges/facilitators.RESULTS: Residents highly rated the narrative medicine curriculum, and the residency program renewed the course for 3 additional years. We identified success factors for programmatic success including time neutrality, control of session, learning climate, building trust, staff partnership, and facilitators training. During control year, resident burnout was initially high (n=16; mean PBWI=3.0, SD: 1.1) and increased by the final week (n=15; PBWI=3.4, SD: 1.6). During implementation year, resident burnout was initially similar (n=13; PBWI=3.1, SD: 1.9) but did not rise as much by rotation end (n=24; PBWI=3.3, SD: 1.6). Implementation was underpowered to detect small effect sizes. Based on our our experience and literature review, we propose an educational competency framework potentially helpful to facilitate inpatient narrative medicine workshops, as a blueprint for other institutions.CONCLUSIONS: Inpatient Narrative Medicine is feasible to implement during a challenging inpatient rotation and may have important short-term effects in mitigating burnout rise, with more study needed. We share teaching tools and propose a competency framework which may be useful to support development of inpatient narrative medicine curricula across institutions.

  View details for DOI 10.1186/s12909-021-02935-x

  View details for PubMedID 34670565

• A Specialized Acute COVID-19 Outpatient Clinic at an Academic Medical Center. American journal of medical quality : the official journal of the American College of Medical Quality Artandi, M., Barman, L., Srinivasan, M., Thomas, S., Singh, J., Asch, S. M., Vilendrer, S. 2021

  Abstract

  Health systems are challenged to provide equitable access to coronavirus disease 2019 (COVID-19) outpatient care during the pandemic. Infected patients may have difficulties accessing regular care and rely on emergency rooms. With the goal to improve system efficiencies and access to care, Stanford launched a designated outpatient COVID-19 "Care and Respiratory Observation of Patients With Novel Coronavirus" clinic in April 2020 in which all adult Stanford patients with newly diagnosed severe acute respiratory syndrome coronavirus 2 were offered follow-up for 2-3 weeks through video, telephone, and in-person encounters. Patients were triaged into risk categories and received home pulse oximeters based on a standardized protocol. Between April 15, 2020, and March 26, 2021, the Care and Respiratory Observation of Patients With Novel Coronavirus clinic enrolled 1317 patients. The clinic provided evaluation of Patients under Investigation, management of acute COVID-19 symptoms, care for COVID-19 patients after hospital discharge, clinical advice, and opportunities for research. The authors share crucial implementation lessons related to team agility, care personalization, and resource optimization.

  View details for DOI 10.1097/JMQ.0000000000000006

  View details for PubMedID 34310381

• Implementing Value-Added Medical Education: Lessons Learned From the Student-Initiated "Stanford Frontline" COVID-19 Consult Service. Academic medicine : journal of the Association of American Medical Colleges Zhou, B., Calkins, C., Jayaraman, T., Cassells, S., Rotto, T., Vaughan, L., Srinivasan, M., Schillinger, E. 2021

  Abstract

  PROBLEM: Value-added medical education (VAME) has been difficult to implement due to student and educator constraints. The COVID-19 pandemic caused a mass transition to online learning, removed students from clinical settings, and underscored students' desires for meaningful VAME opportunities. The authors introduced the Stanford Frontline COVID-19 Consult Service (SFCS), through which off-service medical and physician assistant (PA) students provided assistance to clinicians in the form of rapid research regarding COVID-19 clinical questions.APPROACH: The SFCS, a student-derived VAME initiative, was implemented from March to May 2020 by Stanford University medical students, PA students, and faculty. SFCS aligned with not only the interests of clinicians and students, but also national accreditation standards. Students attended weekly editorial meetings, didactic sessions on literature reviews and information management, and they underwent rigorous training on the peer-review process. After two months, the authors expanded the service to local community clinicians.OUTCOMES: The SFCS enrolled 16 students, was supported by 13 faculty members, and produced 87 peer-reviewed evidence syntheses. Of the 16 SFCS students, 13 (81%) completed evaluations; of 128 Stanford Primary Care and Population Health clinicians, 48 (38%) completed evaluations. Overall student satisfaction with the SFCS was 4.9/5 (standard deviation [SD] 0.3). Self-assessed achievement of SFCS learning objectives exceeded 90% for all objectives. Overall faculty satisfaction with the SFCS was 4.4/5 (SD 0.8). Most faculty (40/46 [87%]) planned to use the database to answer future COVID-19 questions.NEXT STEPS: The SFCS is a novel, student-initiated VAME curriculum focused on increasing students' meaningful contributions to patient care. The authors will track SFCS students throughout their clerkships to gauge clerkship performance/preparedness, and they will develop training for integrating VAME into preclerkship curricula at other institutions. Given its adaptive, student-driven design, the VAME framework used to develop the SFCS empowers students to create their own personalized, experiential learning.

  View details for DOI 10.1097/ACM.0000000000004160

  View details for PubMedID 33983140

• Disaggregating Asian American Cigarette and Alternative Tobacco Product Use: Results from the National Health Interview Survey (NHIS) 2006-2018. Journal of racial and ethnic health disparities Rao, M., Bar, L., Yu, Y., Srinivasan, M., Mukherjea, A., Li, J., Chung, S., Venkatraman, S., Dan, S., Palaniappan, L. 2021

  Abstract

  INTRODUCTION: Asian Americans suffer high rates of smoking and tobacco-related deaths, varying by ethnic group. Trends ofcigarette and alternative tobacco productuse among Asian Americans, specifically considering ethnic group, sex, and nativity, are infrequently reported.METHODS: Using National Health Interview Survey (NHIS) data from 2006-2018 and the 2016-2018 alternative tobacco supplement (e-cigarettes, cigars, smokeless tobacco, pipes), we explored cigarette and alternativetobacco productuse by Asian ethnic group (Asian Indian (n = 4373), Chinese (n = 4736), Filipino (n = 4912)) in comparison to non-Hispanic Whites (NHWs (n = 275,025)), adjusting for socioeconomic and demographic factors.RESULTS: Among 289,046 adults, 12% of Filipinos were current smokers, twice the prevalence in Asian Indians and Chinese (p < 0.001). The male-female gender difference was fivefold for Chinese (10.3% vs. 2.2%; p < 0.001), eightfold for Asian Indians (8.7% vs. 1.1%; p < 0.001), and twofold for Filipinos (16.8% vs. 9.0%). Moreover, 16.3% of US-born and 10.3% of foreign-born Filipinos were current smokers. Odds of ever using e-cigarettes, cigars, smokeless tobacco, and pipes in comparison to NHWs were lowest for Chinese (ORs 0.6, 0.5, 0.2, and 0.5).DISCUSSION: Filipinos had the highest current smoking rates of Asian ethnic groups. Though more Asian men were current smokers, the high rate of current smoking among Filipinas is concerning. More US-born Filipinos were current smokers than foreign-born, despite rates typically decreasing for US-born Asians. Investigating cultural factors contributing to less frequent use of tobacco products, such as alternative tobacco products among Chinese, may aid campaigns in curbing tobacco usage.

  View details for DOI 10.1007/s40615-021-01024-5

  View details for PubMedID 33909281

• Disaggregated Mortality from Gastrointestinal Cancers in Asian Americans: Analysis of United States Death Records. International journal of cancer Huang, R. J., Sharp, N., Talamoa, R., Kapphahn, K., Sathye, V., Lin, B., Srinivasan, M., Palaniappan, L. P. 2021

  Abstract

  Asian Americans (AAs) are heterogeneous, and aggregation of diverse AA populations in national reporting may mask high-risk groups. Gastrointestinal (GI) cancers constitute one-third of global cancer mortality, and an improved understanding of GI cancer mortality by disaggregated AA subgroups may inform future primary and secondary prevention strategies. Using national mortality records from the United States from 2003-2017, we report age-standardized mortality rates, standardized mortality ratios, and annual percent change trends from GI cancers (esophageal, gastric, colorectal, liver, and pancreatic) for the six largest AA subgroups (Asian Indians, Chinese, Filipinos, Japanese, Koreans and Vietnamese). Non-Hispanic Whites (NHWs) are used as the reference population. We found that mortality from GI cancers demonstrated nearly 3-fold difference between the highest (Koreans, 61 per 100 000 person-years) and lowest (Asian Indians, 21 per 100 000 person-years) subgroups. The distribution of GI cancer mortality demonstrates high variability between subgroups, with Korean Americans demonstrating high mortality from gastric cancer (16 per 100 000), and Vietnamese Americans demonstrating high mortality from liver cancer (19 per 100 000). Divergent temporal trends emerged, such as increasing liver cancer burden in Vietnamese Americans, which exacerbated existing mortality differences. There exist striking differences in the mortality burden of GI cancers by disaggregated AA subgroups. These data highlight the need for disaggregated data reporting, and the importance of race-specific and personalized strategies of screening and prevention. This article is protected by copyright. All rights reserved.

  View details for DOI 10.1002/ijc.33490

  View details for PubMedID 33527405

• Transforming Interprofessional Roles During Virtual Health Care: The Evolving Role of the Medical Assistant, in Relationship to National Health Profession Competency Standards. Journal of primary care & community health Rokicki-Parashar, J., Phadke, A., Brown-Johnson, C., Jee, O., Sattler, A., Torres, E., Srinivasan, M. 2021; 12: 21501327211004285

  Abstract

  INTRODUCTION: Medical assistants (MAs) were once limited to obtaining vital signs and office work. Now, MAs are foundational to team-based care, interacting with patients, systems, and teams in many ways. The transition to Virtual Health during the COVID-19 pandemic resulted in a further rapid and unique shift of MA roles and responsibilities. We sought to understand the impact of this shift and to place their new roles in the context of national professional competency standards.METHODS: In this qualitative, grounded theory study we conducted semi-structured interviews with 24 MAs at 10 primary care sites at a major academic medical center on their experiences during the shift from in-person to virtual care. MAs were selected by convenience sample. Coding was done in Dedoose version 8.335. Consensus-based inductive and deductive approaches were used for interview analysis. Identified MA roles were compared to national MA, Institute of Medicine, physician, and nursing professional competency domains.RESULTS: Three main themes emerged: Role Apprehension, Role Expansion, and Adaptability/Professionalism. Nine key roles emerged in the context of virtual visits: direct patient care (pre-visit and physical care), panel management, health systems ambassador, care coordination, patient flow coordination, scribing, quality improvement, and technology support. While some prior MA roles were limited by the virtual care shift, the majority translated directly or expanded in virtual care. Identified roles aligned better with Institute of Medicine, physician, and nursing professional competencies, than current national MA curricula.CONCLUSIONS: The transition to Virtual Health decreased MA's direct clinical work and expanded other roles within interprofessional care, notably quality improvement and technology support. Comparison of the current MA roles with national training program competencies identified new leadership and teamwork competencies which could be expanded during MA training to better support MA roles on inter-professional teams.

  View details for DOI 10.1177/21501327211004285

  View details for PubMedID 33764223

• Qualitative Assessment of Rapid System Transformation to Primary Care Video Visits at an Academic Medical Center. Annals of internal medicine Srinivasan, M. n., Asch, S. n., Vilendrer, S. n., Thomas, S. C., Bajra, R. n., Barman, L. n., Edwards, L. M., Filipowicz, H. n., Giang, L. n., Jee, O. n., Mahoney, M. n., Nelligan, I. n., Phadke, A. J., Torres, E. n., Artandi, M. n. 2020

  Abstract

  The coronavirus disease 2019 pandemic spurred health systems across the world to quickly shift from in-person visits to safer video visits.To seek stakeholder perspectives on video visits' acceptability and effect 3 weeks after near-total transition to video visits.Semistructured qualitative interviews.6 Stanford general primary care and express care clinics at 6 northern California sites, with 81 providers, 123 staff, and 97 614 patient visits in 2019.Fifty-three program participants (overlapping roles as medical providers [n = 20], medical assistants [n = 16], nurses [n = 4], technologists [n = 4], and administrators [n = 13]) were interviewed about video visit transition and challenges.In 3 weeks, express care and primary care video visits increased from less than 10% to greater than 80% and from less than 10% to greater than 75%, respectively. New video visit providers received video visit training and care quality feedback. New system workflows were created to accommodate the new visit method.Nine faculty, trained in qualitative research methods, conducted 53 stakeholder interviews in 4 days using purposeful (administrators and technologists) and convenience (medical assistant, nurses, and providers) sampling. A rapid qualitative analytic approach for thematic analysis was used.The analysis revealed 12 themes, including Pandemic as Catalyst; Joy in Medicine; Safety in Medicine; Slipping Through the Cracks; My Role, Redefined; and The New Normal. Themes were analyzed using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to identify critical issues for continued program utilization.Evaluation was done immediately after deployment. Although viewpoints may have evolved later, immediate evaluation allowed for prompt program changes and identified broader issues to address for program sustainability.After pandemic-related systems transformation at Stanford, critical issues to sustain video visit long-term viability were identified. Specifically, technology ease of use must improve and support multiparty videoconferencing. Providers should be able to care for their patients, regardless of geography. Providers need decision-making support with virtual examination training and home-based patient diagnostics. Finally, ongoing video visit reimbursement should be commensurate with value to the patients' health and well-being.Stanford Department of Medicine and Stanford Health Care.

  View details for DOI 10.7326/M20-1814

  View details for PubMedID 32628536

• The Ethics of Technology for Population Health JOURNAL OF GENERAL INTERNAL MEDICINE Srinivasan, M. 2017; 32 (6): 591–92

  View details for DOI 10.1007/s11606-017-4050-x

  View details for Web of Science ID 000402068300001

  View details for PubMedID 28405791

  View details for PubMedCentralID PMC5442028

• Cultural Influences on Primary Care Delivery JOURNAL OF GENERAL INTERNAL MEDICINE Srinivasan, M. 2016; 31 (11): 1265–66

  View details for DOI 10.1007/s11606-016-3852-6

  View details for Web of Science ID 000386683200001

  View details for PubMedID 27688251

  View details for PubMedCentralID PMC5071305

• Assessing 3rd year medical students' interprofessional collaborative practice behaviors during a standardized patient encounter: A multi-institutional, cross-sectional study. Medical teacher Oza, S. K., Boscardin, C. K., Wamsley, M., Sznewajs, A., May, W., Nevins, A., Srinivasan, M., E Hauer, K. 2015; 37 (10): 915-925

  Abstract

  To understand how third-year medical student interprofessional collaborative practice (IPCP) is affected by self-efficacy and interprofessional experiences (extracurricular experiences and formal curricula).The authors measured learner IPCP using an objective structured clinical examination (OSCE) with a standardized nurse (SN) and standardized patient (SP) during a statewide clinical performance examination. At four California medical schools from April to August 2012, SPs and SNs rated learner IPCP (10 items, range 0-100) and patient-centered communication (10 items, range 0-100). Post-OSCE, students reported their interprofessional self-efficacy (16 items, 2 factors, range 1-10) and prior extracurricular interprofessional experiences (3 items). School representatives shared their interprofessional curricula during guided interviews.Four hundred sixty-four of 530 eligible medical students (88%) participated. Mean IPCP performance was 79.6 ± 14.1 and mean self-efficacy scores were 7.9 (interprofessional teamwork) and 7.1 (interprofessional feedback and evaluation). Seventy percent of students reported prior extracurricular interprofessional experiences; all schools offered formal interprofessional curricula. IPCP was associated with self-efficacy for interprofessional teamwork (β = 1.6, 95% CI [0.1, 3.1], p = 0.04) and patient-centered communication (β = 12.5, 95% CI [2.7, 22.3], p = 0.01).Medical student IPCP performance was associated with self-efficacy for interprofessional teamwork and patient-centered communication. Increasing interprofessional opportunities that influence medical students' self-efficacy may increase engagement in IPCP.

  View details for DOI 10.3109/0142159X.2014.970628

  View details for PubMedID 25313933

• Ethics of Physician Strikes in Health Care INTERNATIONAL ANESTHESIOLOGY CLINICS Li, S. T., Srinivasan, M., Kravitz, R. L., Wilkes, M. S. 2015; 53 (3): 25–38

  View details for DOI 10.1097/AIA.0000000000000054

  View details for Web of Science ID 000218336100004

  View details for PubMedID 26057900

• When Life Span Exceeds Health Span JOURNAL OF GENERAL INTERNAL MEDICINE Srinivasan, M. 2015; 30 (3): 267–68

  View details for DOI 10.1007/s11606-014-3167-4

  View details for Web of Science ID 000350886500001

  View details for PubMedID 25650258

  View details for PubMedCentralID PMC4351270

• A Comparison of Web-Based and Small-Group Palliative and End-of-Life Care Curricula: A Quasi-Randomized Controlled Study at One Institution ACADEMIC MEDICINE Day, F. C., Srinivasan, M., Der-Martirosian, C., Griffin, E., Hoffman, J. R., Wilkes, M. S. 2015; 90 (3): 331–37

  Abstract

  Few studies have compared the effect of Web-based eLearning versus small-group learning on medical student outcomes. Palliative and end-of-life (PEOL) education is ideal for this comparison, given uneven access to PEOL experts and content nationally.In 2010, the authors enrolled all third-year medical students at the University of California, Davis School of Medicine into a quasi-randomized controlled trial of Web-based interactive education (eDoctoring) compared with small-group education (Doctoring) on PEOL clinical content over two months. Students participated in three 3-hour PEOL sessions with similar content. Outcomes included a 24-item PEOL-specific self-efficacy scale with three domains (diagnosis/treatment [Cronbach alpha=0.92; CI: 0.91-0.93], communication/prognosis [alpha=0.95; CI: 0.93-0.96], and social impact/self-care [alpha=0.91; CI: 0.88-0.92]); 8 knowledge items; 10 curricular advantage/disadvantages; and curricular satisfaction (both students and faculty).Students were randomly assigned to Web-based eDoctoring (n=48) or small-group Doctoring (n=71) curricula. Self-efficacy and knowledge improved equivalently between groups (e.g., prognosis self-efficacy, 19%; knowledge, 10%-42%). Student and faculty ratings of the Web-based eDoctoring curriculum and the small-group Doctoring curriculum were equivalent for most goals, and overall satisfaction was equivalent for each, with a trend toward decreased eDoctoring student satisfaction.Findings showed equivalent gains in self-efficacy and knowledge between students participating in a Web-based PEOL curriculum in comparison with students learning similar content in a small-group format. Web-based curricula can standardize content presentation when local teaching expertise is limited, but it may lead to decreased user satisfaction.

  View details for DOI 10.1097/ACM.0000000000000607

  View details for Web of Science ID 000350579800023

  View details for PubMedID 25539518

  View details for PubMedCentralID PMC4340770

• Training Residents for a New System of Primary Care ACADEMIC MEDICINE Dow, A., Li, S. T., Srinivasan, M. 2014; 89 (11): 1442–43

  View details for DOI 10.1097/ACM.0000000000000476

  View details for Web of Science ID 000343897500013

  View details for PubMedID 25350337

• Life Chaos and Intrinsic Motivation JOURNAL OF GENERAL INTERNAL MEDICINE Srinivasan, M. 2014; 29 (9): 1213–14

  View details for DOI 10.1007/s11606-014-2952-4

  View details for Web of Science ID 000340936600001

  View details for PubMedID 25092005

  View details for PubMedCentralID PMC4139523

• Do We Get What We Pay For? Transitioning Physician Payments Towards Value and Efficiency JOURNAL OF GENERAL INTERNAL MEDICINE Srinivasan, M., Schwartz, M. D. 2014; 29 (5): 691–92

  View details for DOI 10.1007/s11606-014-2818-9

  View details for Web of Science ID 000338205700001

  View details for PubMedID 24627268

  View details for PubMedCentralID PMC4000351

• BMJ Endgames: A New Web-Based BMJ/JGIM Collaboration JOURNAL OF GENERAL INTERNAL MEDICINE Srinivasan, M., Mehta, N. 2014; 29 (3): 423–24

  View details for DOI 10.1007/s11606-013-2758-9

  View details for Web of Science ID 000331962600001

  View details for PubMedID 24395105

  View details for PubMedCentralID PMC3930788

• Discussing Uncertainty and Risk in Primary Care: Recommendations of a Multi-Disciplinary Panel Regarding Communication Around Prostate Cancer Screening JOURNAL OF GENERAL INTERNAL MEDICINE Wilkes, M., Srinivasan, M., Cole, G., Tardif, R., Richardson, L. C., Plescia, M. 2013; 28 (11): 1410–19

  Abstract

  Shared decision making improves value-concordant decision-making around prostate cancer screening (PrCS). Yet, PrCS discussions remain complex, challenging and often emotional for physicians and average-risk men.In July 2011, the Centers for Disease Control and Prevention convened a multidisciplinary expert panel to identify priorities for funding agencies and development groups to promote evidence-based, value-concordant decisions between men at average risk for prostate cancer and their physicians.Two-day multidisciplinary expert panel in Atlanta, Georgia, with structured discussions and formal consensus processes.Sixteen panelists represented diverse specialties (primary care, medical oncology, urology), disciplines (sociology, communication, medical education, clinical epidemiology) and market sectors (patient advocacy groups, Federal funding agencies, guideline-development organizations).Panelists used guiding interactional and evaluation models to identify and rate strategies that might improve PrCS discussions and decisions for physicians, patients and health systems/society. Efficacy was defined as the likelihood of each strategy to impact outcomes. Effort was defined as the relative amount of effort to develop, implement and sustain the strategy. Each strategy was rated (1-7 scale; 7 = maximum) using group process software (ThinkTank(TM)). For each group, intervention strategies were grouped as financial/regulatory, educational, communication or attitudinal levers. For each strategy, barriers were identified.Highly ranked strategies to improve value-concordant shared decision-making (SDM) included: changing outpatient clinic visit reimbursement to reward SDM; development of evidence-based, technology-assisted, point-of-service tools for physicians and patients; reframing confusing prostate cancer screening messages; providing pre-visit decision support interventions; utilizing electronic health records to promote benchmarking/best practices; providing additional training for physicians around value-concordant decision-making; and using re-accreditation to promote training.Conference outcomes present an expert consensus of strategies likely to improve value-concordant prostate cancer screening decisions. In addition, the methodology used to obtain agreement provides a model of successful collaboration around this and future controversial cancer screening issues, which may be of interest to funding agencies, educators and policy makers.

  View details for DOI 10.1007/s11606-013-2419-z

  View details for Web of Science ID 000325774800011

  View details for PubMedID 23649782

  View details for PubMedCentralID PMC3797347

• Physician Communication Regarding Prostate Cancer Screening: Analysis of Unannounced Standardized Patient Visits ANNALS OF FAMILY MEDICINE Feng, B., Srinivasan, M., Hoffman, J. R., Rainwater, J. A., Griffin, E., Dragojevic, M., Day, F. C., Wilkes, M. S. 2013; 11 (4): 315–23

  Abstract

  Prostate cancer screening with prostate-specific antigen (PSA) is a controversial issue. The present study aimed to explore physician behaviors during an unannounced standardized patient encounter that was part of a randomized controlled trial to educate physicians using a prostate cancer screening, interactive, Web-based module.Participants included 118 internal medicine and family medicine physicians from 5 health systems in California, in 2007-2008. Control physicians received usual education about prostate cancer screening (brochures from the Center for Disease Control and Prevention). Intervention physicians participated in the prostate cancer screening module. Within 3 months, all physicians saw unannounced standardized patients who prompted prostate cancer screening discussions in clinic. The encounter was audio-recorded, and the recordings were transcribed. Authors analyzed physician behaviors around screening: (1) engagement after prompting, (2) degree of shared decision making, and (3) final recommendations for prostate cancer screening.After prompting, 90% of physicians discussed prostate cancer screening. In comparison with control physicians, intervention physicians showed somewhat more shared decision making behaviors (intervention 14 items vs control 11 items, P <.05), were more likely to mention no screening as an option (intervention 63% vs control 26%, P <.05), to encourage patients to consider different screening options (intervention 62% vs control 39%, P <.05) and seeking input from others (intervention 25% vs control 7%, P<.05).A brief Web-based interactive educational intervention can improve shared decision making, neutrality in recommendation, and reduce PSA test ordering. Engaging patients in discussion of the uses and limitations of tests with uncertain value can decrease utilization of the tests.

  View details for DOI 10.1370/afm.1509

  View details for Web of Science ID 000336798500004

  View details for PubMedID 23835817

  View details for PubMedCentralID PMC3704491

• Pairing Physician Education With Patient Activation to Improve Shared Decisions in Prostate Cancer Screening: A Cluster Randomized Controlled Trial ANNALS OF FAMILY MEDICINE Wilkes, M. S., Day, F. C., Srinivasan, M., Griffin, E., Tancredi, D. J., Rainwater, J. A., Kravitz, R. L., Bell, D. S., Hoffman, J. R. 2013; 11 (4): 324–34

  Abstract

  Most expert groups recommend shared decision making for prostate cancer screening. Most primary care physicians, however, routinely order a prostate-specific antigen (PSA) test with little or no discussion about whether they believe the potential benefits justify the risk of harm. We sought to assess whether educating primary care physicians and activating their patients to ask about prostate cancer screening had a synergistic effect on shared decision making, rates and types of discussions about prostate cancer screening, and the physician's final recommendations.Our study was a cluster randomized controlled trial among primary care physicians and their patients, comparing usual education (control), with physician education alone (MD-Ed), and with physician education and patient activation (MD-Ed+A). Participants included 120 physicians in 5 group practices, and 712 male patients aged 50 to 75 years. The interventions comprised a Web-based educational program for all intervention physicians and MD-Ed+A patients compared with usual education (brochures from the Centers for Disease Control and Prevention). The primary outcome measure was patients' reported postvisit shared decision making regarding prostate cancer screening; secondary measures included unannounced standardized patients' reported shared decision making and the physician's recommendation for prostate cancer screening.Patients' ratings of shared decision making were moderate and did not differ between groups. MD-Ed+A patients reported that physicians had higher prostate cancer screening discussion rates (MD-Ed+A = 65%, MD-Ed = 41%, control=38%; P <.01). Standardized patients reported that physicians seeing MD-Ed+A patients were more neutral during prostate cancer screening recommendations (MD-Ed+A=50%, MD-Ed=33%, control=15%; P <.05). Of the male patients, 80% had had previous PSA tests.Although activating physicians and patients did not lead to significant changes in all aspects of physician attitudes and behaviors that we studied, interventions that involved physicians did have a large effect on their attitudes toward screening and in the discussions they had with patients, including their being more likely than control physicians to engage in prostate cancer screening discussions and more likely to be neutral in their final recommendations.

  View details for DOI 10.1370/afm.1550

  View details for Web of Science ID 000336798500005

  View details for PubMedID 23835818

  View details for PubMedCentralID PMC3704492

• Lessons from psychiatry and psychiatric education for medical learners and teachers INTERNATIONAL REVIEW OF PSYCHIATRY Hilty, D. M., Srinivasan, M., Xiong, G. L., Ferranti, J., Li, S. T. 2013; 25 (3): 329–37

  Abstract

  Medical learners, teachers, and institutions face significant challenges in health care delivery and in training the next generation of clinicians. We propose that psychiatry offers lessons which may help improve how we take care of patients and how we teach others to care for patients. Our objective is to discuss what learners and teachers can learn from psychiatry, organized around (1) how we make decisions, (2) how we learn, and (3) how we reflect on our practice. Information from clinical care, education, neuroscience and other aspects of life (e.g. business, creativity, and research) help us on these processes. We make 'good' decisions in concert with patients and learners, by listening to their experiences, asking questions and exploring subjective and objective information. Our learning has a neurobiological basis, and is effectively furthered by personalization, reinforcement, acquisition of critical thinking skills, and assessment of our limitations and errors. Our ability to reflect is determined by attitude, skill, tolerating ambiguity or dissonance, and planning for the unexpected. These processes - in addition to knowledge and other skills - will help physicians be successful in practice, learning and teaching, research and leadership.

  View details for DOI 10.3109/09540261.2013.794129

  View details for Web of Science ID 000321910600010

  View details for PubMedID 23859096

• The Elusive SIRS Diagnosis JOURNAL OF GENERAL INTERNAL MEDICINE Anderson, I. B., Sudhakar, S., Keenan, C. R., Srinivasan, M. 2013; 28 (3): 470–74

  View details for DOI 10.1007/s11606-012-2203-5

  View details for Web of Science ID 000315434200026

  View details for PubMedID 23054916

  View details for PubMedCentralID PMC3579969

• Implementation outcomes of a multiinstitutional web-based ethical, legal, and social implications genetics curriculum for primary care residents in three specialties GENETICS IN MEDICINE Srinivasan, M., Day, F. C., Griffin, E., Tancredi, D. J., Burke, W., Pinsky, L., Pagon, R. A., Hoffman, J. R., Wilkes, M. S. 2011; 13 (6): 553–62

  Abstract

  Medical genetics lends itself to disseminated teaching methods because of mismatches between numbers of physicians having patients with genetic disorders and availability of genetic specialists.During 3 years, we implemented an interactive, web-based curriculum on ethical, legal, and social implications in medical genetics for primary care residents in three specialties at three institutions. Residents took five (of 10) cases and three (of five) tutorials that varied by specialty. We assessed changes in self-efficacy (primary outcome), knowledge, application, and viewpoints.Overall enrollment was 69% (279/403). One institution did not complete implementation and was dropped from pre-post comparisons. We developed a six-factor ethical, legal, and social implications self-efficacy scale (Cronbach α = 0.95). Baseline self-efficacy was moderate (71/115; range: 23-115) and increased 15% after participation. Pre-post knowledge scores were high and unchanged. Residents reported that this curriculum covered ethical, legal, and social implications/genetics better than their usual curricula. Most (68-91%) identified advantages, especially in providing flexibility and stimulating self-directed learning. After participation, residents reported creating learning goals (66%) and acting on those goals (62%).Ethical, legal, and social implications genetics curricular participation led to modest self-efficacy gains. Residents reported that the curriculum covered unique content areas, had advantages over traditional curriculum, and that they applied ethical, legal, and social implications content clinically. We share lessons from developing and implementing this complex web-based curriculum across multiple institutions.

  View details for DOI 10.1097/GIM.0b013e31820e279a

  View details for Web of Science ID 000291426800009

  View details for PubMedID 21543989

• Developing Personal Values: Trainees' Attitudes Toward Strikes by Health Care Providers ACADEMIC MEDICINE Li, S. T., Srinivasan, M., Der-Martirosian, C., Kravitz, R. L., Wilkes, M. S. 2011; 86 (5): 580–85

  Abstract

  Worldwide, health care providers use strikes and job actions to influence policy. For health care providers, especially physicians, strikes create an ethical tension between an obligation to care for current patients (e.g., to provide care and avoid abandonment) and an obligation to better care for future patients by seeking system improvements (e.g., improvements in safety, to access, and in the composition and strength of the health care workforce). This tension is further intensified when the potential benefit of a strike involves professional self-interest and the potential risk involves patient harm or death. By definition, trainees are still forming their professional identities and values, including their opinions on fair wages, health policy, employee benefits, professionalism, and strikes. In this article, the authors explore these ethical tensions, beginning with a discussion of reactions to a potential 2005 nursing strike at the University of California, Davis, Medical Center. The authors then propose a conceptual model describing factors that may influence health care providers' decisions to strike (including personal ethics, personal agency, and strike-related context). In particular, the authors explore the relationship between training level and attitudes toward taking a job action, such as going on strike. Because trainees' attitudes toward strikes continue to evolve during training, the authors maintain that open discussion around the ethics of health care professionals' strikes and other methods of conflict resolution should be included in medical education to enhance professionalism and systems-based practice training. The authors include sample case vignettes to help initiate these important discussions.

  View details for DOI 10.1097/ACM.0b013e318212b551

  View details for Web of Science ID 000289971300017

  View details for PubMedID 21436671

• It's Not Behcet's! JOURNAL OF GENERAL INTERNAL MEDICINE Liu, Y., Desai, A., Lee, B., Srinivasan, M. 2011; 26 (5): 559–60

  View details for DOI 10.1007/s11606-010-1546-z

  View details for Web of Science ID 000289562700022

  View details for PubMedID 21116869

  View details for PubMedCentralID PMC3077480

• Don't Hold Your Breath JOURNAL OF GENERAL INTERNAL MEDICINE Goyal, V., Srinivasan, M. 2011; 26 (3): 345

  View details for DOI 10.1007/s11606-010-1565-9

  View details for Web of Science ID 000287661800024

  View details for PubMedID 21104037

  View details for PubMedCentralID PMC3043171

• Attributes Affecting the Medical School Primary Care Experience ACADEMIC MEDICINE Jerant, A., Srinivasan, M., Bertakis, K. D., Azari, R., Pan, R. J., Kravitz, R. L. 2010; 85 (4): 605–13

  Abstract

  Favorable primary care (PC) experiences might encourage more medical students to pursue generalist careers, yet academicians know little about which attributes influence the medical school PC experience. The authors sought to identify such attributes and weight their importance.Semistructured interviews with 16 academic generalist leaders of family medicine, general internal medicine, and general pediatrics led to the development of a Web-based survey, administered to a national sample of 126 generalist faculty. Survey respondents rated (on a nine-point Likert-like scale) the importance of each interview-generated PC medical school attribute and indicated (yes/no) whether outside experts' assessment of the attributes would be valid. The authors assessed interrater agreement.Interview thematic analysis generated 58 institutional attributes in four categories: informal curriculum (23), institutional infrastructure (6), educational/curricular infrastructure (6), and specific educational experiences (23). Of these 58, 31 (53%) had median importance ratings of >7 (highly important). For 14 of these (45%), more than two-thirds of respondents indicated external expert surveys would provide a valid assessment. Of the 23 informal curriculum attributes, 20 (87%) received highly important ratings; however, more than two-thirds of respondents believed that external expert survey ratings would be valid for only 4 (20%) of them. Strong agreement occurred among respondents across the generalist fields.Academic generalist educators identified several attributes as highly important in shaping the quality of the medical school PC experience. Informal curriculum attributes appeared particularly influential, but these attributes may not be validly assessed via expert surveys, suggesting the need for other measures.

  View details for DOI 10.1097/ACM.0b013e3181d29af7

  View details for Web of Science ID 000276132300019

  View details for PubMedID 20354375

• From the Editor's Desk: Legislating Change JOURNAL OF GENERAL INTERNAL MEDICINE Srinivasan, M., Feldman, M. D. 2010; 25 (3): 173

  View details for DOI 10.1007/s11606-010-1261-9

  View details for Web of Science ID 000276014300001

  View details for PubMedID 20162374

  View details for PubMedCentralID PMC2839330

• Measuring Knowledge Structure: Reliability of Concept Mapping Assessment in Medical Education ACADEMIC MEDICINE Srinivasan, M., McElvany, M., Shay, J. M., Shavelson, R. J., West, D. C. 2008; 83 (12): 1196-1203

  Abstract

  To test the reliability of concept map assessment, which can be used to assess an individual's "knowledge structure," in a medical education setting.In 2004, 52 senior residents (pediatrics and internal medicine) and fourth-year medical students at the University of California-Davis School of Medicine created separate concept maps about two different subject domains (asthma and diabetes) on two separate occasions each (four total maps). Maps were rated using four different scoring systems: structural (S; counting propositions), quality (Q; rating the quality of propositions), importance/quality (I/Q; rating importance and quality of propositions), and a hybrid system (H; combining elements of S with I/Q). The authors used generalizability theory to determine reliability.Learners (universe score) contributed 40% to 44% to total score variation for the Q, I/Q, and H scoring systems, but only 10% for the S scoring system. There was a large learner-occasion-domain interaction effect (19%-23%). Subsequent analysis of each subject domain separately demonstrated a large learner-occasion interaction effect (31%-37%) and determined that administration on four to five occasions was necessary to achieve adequate reliability. Rater variation was uniformly low.The Q, I/Q, and H scoring systems demonstrated similar reliability and were all more reliable than the S system. The findings suggest that training and practice are required to perform the assessment task, and, as administered in this study, four to five testing occasions are required to achieve adequate reliability. Further research should focus on whether alterations in the concept mapping task could allow it to be administered over fewer occasions while maintaining adequate reliability.

  View details for Web of Science ID 000267654800030

  View details for PubMedID 19202500

• Developing the master educator: Cross disciplinary teaching scholars program for human and veterinary medical faculty ACADEMIC PSYCHIATRY Srinivasan, M., Pratt, D. D., Collins, J., Bowe, C. M., Stevenson, F. T., Pinney, S. J., Wilkes, M. S. 2007; 31 (6): 452–64

  Abstract

  At the University of California, Davis (UCD), the authors sought to develop an institutional network of reflective educational leaders. The authors wanted to enhance faculty understanding of medical education's complexity, and improve educators' effectiveness as regional/national leaders.The UCD Teaching Scholars Program is a half-year course, comprised of 24 weekly half-day small group sessions, for faculty in the School of Medicine and Veterinary Medicine. The program's philosophical framework was centered on personal reflection to enhance change: 1) understanding educational theory to build metacognitive bridges, 2) diversity of perspectives to broaden horizons, 3) colleagues as peer teachers to improve interactive experiences, and 4) reciprocal process of testing theory and examining practice to reinforce learning. The authors describe the program development (environmental analysis, marketing, teaching techniques), specific challenges, and failed experiments. The authors provide examples of interactive exercises used to enhance curricular content. The authors enrolled 7-10 faculty per year, from a diverse pool of current and near-future educational leaders.Four years of Teaching Scholars participants were surveyed about program experiences and short/longer term outcomes. Twenty-six (76%) respondents reported that they were very satisfied with the course (4.6/5), individual curricular blocks (4.2-4.6), and other faculty (4.7). They described participation barriers/facilitators. Participants reported positive impact on their effectiveness as educators (100%), course directors (84%), leaders (72%), and educational researchers (52%). They described specific acquired attitudes, knowledge, and skills. They described changes in their approach to education/career changed based on program participation. Combining faculty from different educational backgrounds significantly broadened perspectives, leading to greater/new collaboration.Developing a cadre of master educators requires careful program planning, implementation, and program/participant evaluation. Based on participant feedback, our program was a success at stimulating change. This open assessment of programmatic strengths and weaknesses may provide a template for other medical institutions that seek to enhance their institutional educational mission.

  View details for DOI 10.1176/appi.ap.31.6.452

  View details for Web of Science ID 000251787400009

  View details for PubMedID 18079507

• Does feedback matter? Practice-based learning for medical students after a multi-institutional clinical performance examination MEDICAL EDUCATION Srinivasan, M., Hauer, K. E., Der-Martirosian, C., Wilkes, M., Gesundheit, N. 2007; 41 (9): 857-865

  Abstract

  Achieving competence in 'practice-based learning' implies that doctors can accurately self- assess their clinical skills to identify behaviours that need improvement. This study examines the impact of receiving feedback via performance benchmarks on medical students' self-assessment after a clinical performance examination (CPX).The authors developed a practice-based learning exercise at 3 institutions following a required 8-station CPX for medical students at the end of Year 3. Standardised patients (SPs) scored students after each station using checklists developed by experts. Students assessed their own performance immediately after the CPX (Phase 1). One month later, students watched their videotaped performance and reassessed (Phase 2). Some students received performance benchmarks (their scores, plus normative class data) before the video review. Pearson's correlations between self-ratings and SP ratings were calculated for overall performance and specific skill areas (history taking, physical examination, doctor-patient communication) for Phase 1 and Phase 2. The 2 correlations were then compared for each student group (i.e. those who received and those who did not receive feedback).A total of 280 students completed both study phases. Mean CPX scores ranged from 51% to 71% of items correct overall and for each skill area. Phase 1 self-assessment correlated weakly with SP ratings of student performance (r = 0.01-0.16). Without feedback, Phase 2 correlations remained weak (r = 0.13-0.18; n = 109). With feedback, Phase 2 correlations improved significantly (r = 0.26-0.47; n = 171). Low-performing students showed the greatest improvement after receiving feedback.The accuracy of student self-assessment was poor after a CPX, but improved significantly with performance feedback (scores and benchmarks). Videotape review alone (without feedback) did not improve self-assessment accuracy. Practice-based learning exercises that incorporate feedback to medical students hold promise to improve self-assessment skills.

  View details for DOI 10.1111/j.1365-2923.2007.02818.x

  View details for Web of Science ID 000249185000004

  View details for PubMedID 17727526

• Comparing problem-based learning with case-based learning: Effects of a major curricular shift at two institutions ACADEMIC MEDICINE Srinivasan, M., Wilkes, M., Stevenson, F., Nguyen, T., Slavin, S. 2007; 82 (1): 74–82

  Abstract

  Problem-based learning (PBL) is now used at many medical schools to promote lifelong learning, open inquiry, teamwork, and critical thinking. PBL has not been compared with other forms of discussion-based small-group learning. Case-based learning (CBL) uses a guided inquiry method and provides more structure during small-group sessions. In this study, we compared faculty and medical students' perceptions of traditional PBL with CBL after a curricular shift at two institutions.Over periods of three years, the medical schools at the University of California, Los Angeles (UCLA) and the University of California, Davis (UCD) changed first-, second-, and third-year Doctoring courses from PBL to CBL formats. Ten months after the shift (2001 at UCLA and 2004 at UCD), students and faculty who had participated in both curricula completed a 24-item questionnaire about their PBL and CBL perceptions and the perceived advantages of each formatA total of 286 students (86%-97%) and 31 faculty (92%-100%) completed questionnaires. CBL was preferred by students (255; 89%) and faculty (26; 84%) across schools and learner levels. The few students preferring PBL (11%) felt it encouraged self-directed learning (26%) and valued its greater opportunities for participation (32%). From logistic regression, students preferred CBL because of fewer unfocused tangents (59%, odds ration [OR] 4.10, P = .01), less busy-work (80%, OR 3.97, P = .01), and more opportunities for clinical skills application (52%, OR 25.6, P = .002).Learners and faculty at two major academic medical centers overwhelmingly preferred CBL (guided inquiry) over PBL (open inquiry). Given the dense medical curriculum and need for efficient use of student and faculty time, CBL offers an alternative model to traditional PBL small-group teaching. This study could not assess which method produces better practicing physicians.

  View details for DOI 10.1097/01.ACM.0000249963.93776.aa

  View details for Web of Science ID 000243237200010

  View details for PubMedID 17198294

• Connoisseurs of care? Unannounced standardized patients' ratings of physicians MEDICAL CARE Srinivasan, M., Franks, P., Meredith, L. S., Fiscella, K., Epstein, R. M., Kravitz, R. L. 2006; 44 (12): 1092–98

  Abstract

  Patient satisfaction surveys can be informative, but bias and poor response rates may limit their utility as stable measures of physician performance. Using unannounced standardized patients (SPs) may overcome some of these limitations because their experience and training make them able judges of physician behavior.We sought to understand the reliability of unannounced SPs in rating primary care physicians when covertly presenting as real patients.Data from 2 studies (Patient Centered Communication [PCC]; Social Influences in Practice [SIP]) were included. For the PCC study, 5 SPs made 192 visits to 96 physicians; for the SIP study, 18 SPs made 292 visits to 146 physicians. SPs visits to physicians were randomized, thus avoiding mutual selection bias. Each SP rated 16 to 38 physicians on interpersonal skills (autonomy support: PCC, SIP), technical skills (information gathering: SIP-only), and overall satisfaction (SIP-only). We evaluated SP evaluation consistency (physician vs. total variance rho), and SPs' overall satisfaction with specific dimensions of physician performance.Scale reliability varied from 0.71 to 0.92. Physician rhos (95% confidence intervals) for autonomy support were 0.40 (0.22-0.58; PCC) and 0.30 (0.14-0.45; SIP); information gathering rho was 0.46 (0.33-0.59; SIP). Overall SP satisfaction rho was 0.47 (0.34-0.60; SIP). SPs varied significantly in adjusted overall satisfaction levels, but not other dimensions.These analyses provide some evidence that medical connoisseurship can be learned. When adequately sampled by trained SPs, some physician skills can be reliably measured in community practice settings.

  View details for DOI 10.1097/01.mlr.0000237197.92152.5e

  View details for Web of Science ID 000242477200006

  View details for PubMedID 17122713

• Electronic medical records and their impact on resident and medical student education ACADEMIC PSYCHIATRY Keenan, C. R., Nguyen, H. H., Srinivasan, M. 2006; 30 (6): 522–27

  Abstract

  Electronic medical records (EMRs) are becoming prevalent and integral tools for residents and medical students. EMRs can integrate point-of-service information delivery within the context of patient care. Though it may be an educational tool, little is known about how EMR technology is currently used for medical learners.The authors reviewed the available published literature about the impact of EMRs on learners, including learners' attitudes about EMRs, educational uses of EMRs, and the potential effects of EMRs on learners' daily work.Research on EMRs for education is in its infancy. The authors found fewer than 50 articles with evidence on their use in medical education. The applications to education included point-of-care knowledge delivery, computerized clinical decision support systems, profiling of learner experiences, and daily workflow management. The evidence was mainly derived from single institution studies and occasionally across disciplines.EMRs have great potential as an educational tool, but thus far, strong data to support their use for this are lacking. As the usage of EMRs rises, educators must continue to study how best to use technology as an educational tool and as a tool to improve the daily work of residents and medical students.

  View details for DOI 10.1176/appi.ap.30.6.522

  View details for Web of Science ID 000242420200014

  View details for PubMedID 17139024

• Visualizing the future: Technology competency development in clinical medicine, and implications for medical education ACADEMIC PSYCHIATRY Srinivasan, M., Keenan, C. R., Yager, J. 2006; 30 (6): 480–90

  Abstract

  In this article, the authors ask three questions. First, what will physicians need to know in order to be effective in the future? Second, what role will technology play in achieving that high level of effectiveness? Third, what specific skill sets will physicians need to master in order to become effective?Through three case vignettes describing past, present, and potential future medical practices, the authors identify trends in major medical, technological and cultural shifts that will shape medical education and practice.From these cases, the authors generate a series of technology-related competencies and skill sets that physicians will need to remain leaders in the delivery of medical care. Physicians will choose how they will be end-users of technology, technology developers, and/or the interface between users and developers. These choices will guide the types of skills each physician will need to acquire. Finally, the authors explore the implications of these trends for medical educators, including the competencies that will be required of educators as they develop the medical curriculum.Examining historical and social trends, including how users adopt current and emerging technologies, allows us to anticipate changes in the practice of medicine. By considering market pressures, global trends and emerging technologies, medical educators and practicing physicians may prepare themselves for the changes likely to occur in the medical curriculum and in the marketplace.

  View details for DOI 10.1176/appi.ap.30.6.480

  View details for Web of Science ID 000242420200009

  View details for PubMedID 17139019

• Assessment of clinical skills using simulator technologies ACADEMIC PSYCHIATRY Srinivasan, M., Hwang, J. C., West, D., Yellowlees, P. M. 2006; 30 (6): 505–15

  Abstract

  Simulation technologies are used to assess and teach competencies through the provision of reproducible stimuli. They have exceptional utility in assessing responses to clinical stimuli that occur sporadically or infrequently. In this article, the authors describe the utility of emerging simulation technologies, and discuss critical issues in simulator-based skills assessment and appropriate results analysis.Based on literature search and expert consensus, the authors discuss three simulation technologies: standardized patients and the objective structured clinical examination; the integrated high fidelity mannequin; virtual clinical stations and the objective structured virtual examination.The authors explore the current state of these technologies: uses, cost, limitations, and likely future applications. For instance, tele-standardized patients may test learners' communication/management approach to challenges during tele-consultation, such as a suicidal patient several hundred miles away. Integrated mannequins may test leadership skills during psychiatric emergencies. Case-based interactive virtual clinical assessment tools may test learners' decision-making skills or self-reflection. However, these exciting tools must be implemented systematically. Specifically, educators must define the competencies of interest precisely. Appropriate data analysis will generate dependable results, ascribing the correct proportion of outcome variability to individual learner behavior. Careful analysis and utilization of results will allow justification of the costs to major stakeholders.Simulation technologies offer exciting possibilities for skills evaluation and clinical practice improvement. When used creatively and appropriately, they form a useful adjunct in the armament of educators addressing the question, "Is this physician competent?"

  View details for DOI 10.1176/appi.ap.30.6.505

  View details for Web of Science ID 000242420200012

  View details for PubMedID 17139022

• Patient desires: a model for assessment of patient preferences for care of severe or terminal illness. Palliative & supportive care Knops, K. M., Srinivasan, M., Meyers, F. J. 2005; 3 (4): 289–99

  Abstract

  OBJECTIVE: Patient-centered care is better achieved through a comprehensive understanding of patients' preferences for how they want to live their life and how they want to influence their own death. Though much has been written on identifying goals of care, it is often difficult for clinicians to articulate patient goals to guide care planning. We explored the literature on patient's preferences for their care in chronic or life-limiting illness to develop a model for assessment of patient perspectives. We then illustrated our model with composite patients from our clinics and we provide questions to guide patient discussion.METHODS: We searched MEDLINE from 1986 to 2004 for primary research articles that relate primarily to a patient's preferences for his or her care. We reviewed over 3500 titles, abstracts, and research papers. Hundreds of articles described patients' quality of life, health status, or satisfaction. We excluded consensus guidelines, non-English papers, reviews, and articles focused on medical professional perspectives. Forty-eight studies focused primarily on patient preferences. Using an iterative process, we identified unique issues and broader themes in patients' desires for their care.RESULTS: Studies focused on patients with cancer, those in hospice or those with terminal disease. Three domains emerged: patient feelings about disease, feelings about suffering, and feelings about the circumstances of death. Attention was given to the differences between patients in terms of the strength and persistence of feelings in each domain.SIGNIFICANCE OF RESULTS: Based on existing data, there are three fundamental domains of patient perspective that influence preferences for care. These domains can be assessed by the care team to guide the development of a plan of care and to identify areas of conflict. Our review identifies gaps in the end-of-life literature and areas for future work in patient preferences.

  View details for PubMedID 17039984

• Effective organizational control: Implications for academic medicine ACADEMIC MEDICINE Wilkes, M. S., Srinivasan, M., Flamholtz, E. 2005; 80 (11): 1054–63

  Abstract

  This article provides a framework for understanding the nature, role, functioning, design, and effects of organizational oversight systems. Using a case study with elements recognizable to an academic audience, the authors explore how a dean of a fictitious School of Medicine might use organizational control structures to develop effective solutions to global disarray within the academic medical center. Organizational control systems are intended to help influence the behavior of people as members of a formal organization. They are necessary to motivate people toward organizational goals, to coordinate diverse efforts, and to provide feedback about problems. The authors present a model of control to make this process more visible within organizations. They explore the overlap among academic medical centers and large businesses-for instance, each is a billion-dollar enterprise with complex internal and external demands and multiple audiences. The authors identify and describe how to use the key components of an organization's control system: environment, culture, structure, and core control system. Elements of the core control system are identified, described, and explored. These closely articulating elements include planning, operations, measurement, evaluation, and feedback systems. Use of control portfolios is explored to achieve goal-outcome congruence. Additionally, the authors describe how the components of the control system can be used synergistically by academic leadership to create organizational change, congruent with larger organizational goals. The enterprise of medicine is quickly learning from the enterprise of business. Achieving goal-action congruence will better position academic medicine to meet its multiple missions.

  View details for DOI 10.1097/00001888-200511000-00014

  View details for Web of Science ID 000232906100013

  View details for PubMedID 16249305

• Factors affecting resident performance: Development of a theoretical model and a focused literature review ACADEMIC MEDICINE Mitchell, M., Srinivasan, M., West, D. C., Franks, P., Keenan, C., Henderson, M., Wilkes, M. 2005; 80 (4): 376–89

  Abstract

  The clinical performances of physicians have come under scrutiny as greater public attention is paid to the quality of health care. However, determinants of physician performance have not been well elucidated. The authors sought to develop a theoretical model of physician performance, and explored the literature about factors affecting resident performance.Using expert consensus panel, in 2002-03 the authors developed a hypothesis-generating model of resident performance. The developed model had three input factors (individual resident factors, health care infrastructure, and medical education infrastructure), intermediate process measures (knowledge, skills, attitudes, habits), and final health outcomes (affecting patient, community and population). The authors used factors from the model to focus a PubMed search (1967-2002) for all original articles related to the factors of individual resident performance.The authors found 52 original studies that examined factors of an individual resident's performance. They describe each study's measurement instrument, study design, major findings, and limitations. Studies were categorized into five domains: learning styles/personality, social/financial factors, practice preferences, personal health, and response to job environment. Few studies examined intermediate or final performance outcomes. Most were single-institution, cross-sectional, and survey-based studies.Attempting to understand resident performance without understanding factors that influence performance is analogous to examining patient adherence to medication regimens without understanding the individual patient and his or her environment. Based on a systematic review of the literature, the authors found few discrete associations between the factors of individual resident and the resident's actual job performance. Additionally, they identify and discuss major gaps in the educational literature.

  View details for DOI 10.1097/00001888-200504000-00016

  View details for Web of Science ID 000227924700013

  View details for PubMedID 15793024

• Developing an OSTE to address lapses in learners' professional behavior and an instrument to code educators' responses ACADEMIC MEDICINE Srinivasan, M., Litzelman, D., Seshadri, R., Lane, K., Zhou, W., Bogdewic, S., Gaffney, M., Galvin, M., Mitchell, G., Treadwell, P., Willis, L. 2004; 79 (9): 888–96

  Abstract

  To develop an instrument for measuring medical educators' responses to learners' lapses in professional behavior.In 1999, at the Indiana University School of Medicine, a 22-item checklist of behaviors was developed to describe common responses used by educators responding to learners' lapses in professional behavior. Four medical students were trained to portray lapses in professional behaviors. These students and seven clinical observers trained to categorize behaviors as present or absent. Interrater reliability was assessed during 18 objective structured teaching evaluations (OSTEs). Videotaped OSTEs were coded twice at a one-month interval for test-retest reliability. Items were classified as low, moderate, or high inference behaviors. Script realism and educator effectiveness were assessed.Educators rated OSTE scripts as realistic. Raters observed an average of 6 +/- 2 educator behaviors in reaction to learners' lapses in professional behavior. Educators' responses were rated as moderately effective. More experienced educators attempted more interventions and were more effective. Agreement was high among raters (86% +/- 7%), while intraclass correlation coefficients decreased with increasing inference level. From videotaped OSTEs, raters scored each behavior identically 86% of the time.Accurate feedback on educators' interactions in addressing learners' professionalism is essential for faculty development. Traditionally, educators have felt that faculty's responses to learners' lapses in professional behavior were difficult to observe and categorize. These data suggest that educators' responses to learners' lapses in professional behavior can be defined and reliably coded. This work will help provide objective feedback to faculty when engaging learners about lapses in professional behavior.

  View details for DOI 10.1097/00001888-200409000-00017

  View details for Web of Science ID 000223562200013

  View details for PubMedID 15326017

• Early introduction of an evidence-based medicine course to preclinical medical students Srinivasan, M., Weiner, M., Breitfeld, P. P., Brahmi, F., Dickerson, K. L., Weiner, G. BLACKWELL PUBLISHING INC. 2002: 58–65

  Abstract

  Evidence-based Medicine (EBM) has been increasingly integrated into medical education curricula. Using an observational research design, we evaluated the feasibility of introducing a 1-month problem-based EBM course for 139 first-year medical students at a large university center. We assessed program performance through the use of a web-based curricular component and practice exam, final examination scores, student satisfaction surveys, and a faculty questionnaire. Students demonstrated active involvement in learning EBM and ability to use EBM principles. Facilitators felt that students performed well and compared favorably with residents whom they had supervised in the past year. Both faculty and students were satisfied with the EBM course. To our knowledge, this is the first report to demonstrate that early introduction of EBM principles as a short course to preclinical medical students is feasible and practical.

  View details for DOI 10.1046/j.1525-1497.2002.10121.x

  View details for Web of Science ID 000175032900007

  View details for PubMedID 11903776

  View details for PubMedCentralID PMC1494995

• Predictors of self care behaviors of diabetes type I adults in the Oregon Health Plan Srinivasan, M., McNeill, A., Garfinkel, S., Swigonski, N. LIPPINCOTT WILLIAMS & WILKINS. 2000: 268A

  View details for Web of Science ID 000089038200216