Malathi Srinivasan

All Publications

• Feasibility and Acceptability of Universal Adult Screening for Chronic Hepatitis B in Primary Care Clinics. AJPM focus Chu, R. V., Sarnala, S., Doan, T. V., Jamal, A., Phadke, A., So, S., So, R., Pham, H., Chaudhary, J., Huang, R., Kim, G., Palaniappan, L., Kim, K., Srinivasan, M. 2024; 3 (6): 100240

  Abstract

  Two thirds of Americans infected with chronic hepatitis B are unaware of their infection. In March 2023, the Centers for Disease Control and Prevention recommended moving from risk-based to universal adult chronic hepatitis B screening. In April 2022, Stanford implemented chronic hepatitis B universal screening discussion alerts for primary care providers.After 6 months, the authors surveyed 143 primary care providers at 13 Stanford primary care clinics about universal chronic hepatitis B screening acceptability and implementation feasibility. They conducted semistructured interviews with 15 primary care providers and 5 medical assistants around alerts and chronic hepatitis B universal versus risk-based screening.Forty-five percent of surveyed primary care providers responded. A total of 63% reported that universal screening would identify more patients with chronic hepatitis B. Before implementation, 77% ordered 0-5 chronic hepatitis B screenings per month. After implementation, 71% ordered >6 screenings per month. A total of 66% shared that universal screening removed the stigma around discussing high-risk behaviors. Interview themes included (1) low clinical burden, (2) current underscreening of at-risk groups, (3) providers preferring universal screening, (4) patients accepting universal screening, and (5) ease of chronic hepatitis B alert implementation.Consistent with Centers for Disease Control and Prevention guidelines, implementing universal chronic hepatitis B screening in primary care clinics in Northern California was feasible, was acceptable to providers and patients, eased health maintenance burdens, and improved clinic workflows.

  View details for DOI 10.1016/j.focus.2024.100240

  View details for PubMedID 39582739

  View details for PubMedCentralID PMC11584556

• Cancer Mortality among Hispanic groups in the US, by birthplace (2003-2017). Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology He, Y., Pinheiro, P. S., Tripathi, O., Nguyen, H., Srinivasan, M., Palaniappan, L. P., Thompson, C. A. 2024

  Abstract

  BACKGROUND: The Hispanic population is the second largest racial/ethnic group in the US, consisting of multiple distinct ethnicities. Ethnicity-specific variations in cancer mortality may be attributed to countries of birth, so we aimed to understand differences in cancer mortality among disaggregated Hispanics by nativity (native- or foreign- born vs. US-born) over 15 years.METHODS: 228,197 Hispanic decedents (Mexican, Puerto Rican [PR], Cuban, and Central or South American) with cancer-related deaths from US death certificates (2003-2017) were analyzed. Seven cancers that contribute significantly to Hispanic male (lung and bronchus, colon and rectum, liver, prostate, and pancreas cancers) and female (lung and bronchus, liver, pancreas, colon and rectum, female breast, and ovary cancers) mortality were selected for analysis. 5-year age-adjusted mortality rates [AAMR (95% CI); per 100,000] and standardized mortality ratios [SMR (95% CI)] using foreign-born as the reference group were calculated. Joinpoint regression analysis was used to model cancer-related mortality trends.RESULTS: Puerto Rico-born PRs, Cuba-born Cubans, and US-born Mexicans had some of the highest cancer death rates among all the Hispanic groups. In general, foreign-born Hispanics had higher cancer mortality rates than US-born, except Mexicans. Overall, US-born and non-US-born (i.e. native- or foreign- born) Hispanic groups experienced decreasing rates of cancer deaths over the years.CONCLUSIONS: We noted vast heterogeneity in mortality rates by nativity across Hispanic groups, a fast-growing diverse US population.IMPACT: Understanding disaggregated patterns and trends in cancer burden can motivate deeper discussion around community health resources, which may improve the health of Hispanics across the US.

  View details for DOI 10.1158/1055-9965.EPI-24-0792

  View details for PubMedID 39361352

• Bridging the Telehealth Digital Divide With Collegiate Navigators: Mixed Methods Evaluation Study of a Service-Learning Health Disparities Course. JMIR medical education Doueiri, Z. N., Bajra, R., Srinivasan, M., Schillinger, E., Cuan, N. 2024; 10: e57077

  Abstract

  BACKGROUND: Limited digital literacy is a barrier for vulnerable patients accessing health care.OBJECTIVE: The Stanford Technology Access Resource Team (START), a service-learning course created to bridge the telehealth digital divide, trained undergraduate and graduate students to provide hands-on patient support to improve access to electronic medical records (EMRs) and video visits while learning about social determinants of health.METHODS: START students reached out to 1185 patients (n=711, 60% from primary care clinics of a large academic medical center and n=474, 40% from a federally qualified health center). Registries consisted of patients without an EMR account (at primary care clinics) or patients with a scheduled telehealth visit (at a federally qualified health center). Patient outcomes were evaluated by successful EMR enrollments and video visit setups. Student outcomes were assessed by reflections coded for thematic content.RESULTS: Over 6 academic quarters, 57 students reached out to 1185 registry patients. Of the 229 patients contacted, 141 desired technical support. START students successfully established EMR accounts and set up video visits for 78.7% (111/141) of patients. After program completion, we reached out to 13.5% (19/141) of patients to collect perspectives on program utility. The majority (18/19, 94.7%) reported that START students were helpful, and 73.7% (14/19) reported that they had successfully connected with their health care provider in a digital visit. Inability to establish access included a lack of Wi-Fi or device access, the absence of an interpreter, and a disability that precluded the use of video visits. Qualitative analysis of student reflections showed an impact on future career goals and improved awareness of health disparities of technology access.CONCLUSIONS: Of the patients who desired telehealth access, START improved access for 78.7% (111/141) of patients. Students found that START broadened their understanding of health disparities and social determinants of health and influenced their future career goals.

  View details for DOI 10.2196/57077

  View details for PubMedID 39353186

• Opioid overdose deaths are prominent in urban counties within the USA: an observational cross-sectional study. British journal of anaesthesia Patankar, A. V., Octaviano, R., Gurachar, N., Chen, A. W., Guan, A., Hung, G. A., Kikuta, N., Jamal, A., Srinivasan, M., Bacong, A. M., Huang, R. J., Kim, G. S., Palaniappan, L. P., Gross, E. R. 2024

  View details for DOI 10.1016/j.bja.2024.07.020

  View details for PubMedID 39209699

• Nasopharyngeal cancer mortality in disaggregated Asian and non-Asian Americans. Head & neck Hung, G. A., Vohra, S., Kim, G., Jamal, A., Srinivasan, M., Huang, R. J., Kim, G., Palaniappan, L., Colevas, A. D. 2024

  Abstract

  Nasopharyngeal carcinoma (NPC) mortality varies based on multiple risk factors. While NPC mortality is higher in Asia, little is known about Asian subgroups in the United States (US).Using the 2005-2020 National Vital Statistics System, we examined NPC mortality by age, race (non-Hispanic black, Hispanic white (HW), non-Hispanic white (NHW), Chinese, Filipino, Asian Indian, Japanese, Korean, Vietnamese), sex, and nativity (Untied States or foreign-born).Upon disaggregation, Chinese (1.96 [CI: 1.78-2.16]), Filipino (0.68 [0.68-1.11]), and Vietnamese Americans (0.68 [0.52-1.10]) had the top age-adjusted mortality rates (AAMR per 100 000 person-years). Foreign-born Chinese, Vietnamese, Filipinos, Asian Indians, and NHW had higher AAMRs compared to US-born persons. All male groups had higher AAMR compared to females. Stratifying for race, nativity, and sex, foreign-born Chinese males (4.09 [3.79-4.40]) had the highest AAMR.These findings demonstrate the importance of disaggregating NPC mortality data by Asian subgroups, providing valuable insights for targeted public health interventions in the United States.

  View details for DOI 10.1002/hed.27857

  View details for PubMedID 39022914

• Nasopharyngeal cancer mortality in disaggregated Asian and non-Asian Americans Hung, G. A., Vohra, S., Kim, G., Jamal, A., Srinivasan, M., Huang, R. J., Kim, G., Palaniappan, L., Colevas, A. LIPPINCOTT WILLIAMS & WILKINS. 2024

  View details for Web of Science ID 001275557404830

• Leading causes of death in Vietnamese Americans: An ecological study based on national death records from 2005-2020. PloS one Tran, K., Shon, H., Phan, J., Cheng, T., Kim, G. S., Jamal, A., Srinivasan, M., Palaniappan, L. P., Nguyen, L., Huang, R. J. 2024; 19 (5): e0303195

  Abstract

  Disaggregated data is a cornerstone of precision health. Vietnamese Americans (VietAms) are the fourth-largest Asian subgroup in the United States (US), and demonstrate a unique burden of disease and mortality. However, most prior studies have aggregated VietAms under the broader Asian American category for analytic purposes. This study examined the leading causes of death among VietAms compared to aggregated Asian Americans and non-Hispanic Whites (NHWs) during the period 2005-2020.Decedent data, including underlying cause of death, were obtained from the National Center for Health Statistics national mortality file from 2005 to 2020. Population denominator estimates were obtained from the American Community Survey one-year population estimates. Outcome measures included proportional mortality, age-adjusted mortality rates per 100,000 (AMR), and annual percent change (APC) in mortality over time. Data were stratified by sex and nativity status. Due to large differences in age structure, we report native- and foreign-born VietAms separately.We identified 74,524 VietAm decedents over the study period (71,305 foreign-born, 3,219 native-born). Among foreign-born VietAms, the three leading causes of death were cancer (26.6%), heart disease (18.0%), and cerebrovascular disease (9.0%). Among native-born VietAms the three leading causes were accidents (19.0%), self-harm (12.0%), and cancer (10.4%). For every leading cause of death, VietAms exhibited lower mortality compared to both aggregated Asians and NHWs. Over the course of the study period, VietAms witnessed an increase in mortality in every leading cause. This effect was mostly driven by foreign-born, male VietAms.While VietAms have lower overall mortality from leading causes of death compared to aggregated Asians and NHWs, these advantages have eroded markedly between 2005 and 2020. These data emphasize the importance of racial disaggregation in the reporting of public health measures.

  View details for DOI 10.1371/journal.pone.0303195

  View details for PubMedID 38787829

• Social Determinants of Cardiovascular Risk Factors Among Asian American Subgroups. Journal of the American Heart Association Zhu, A. L., Le, A. D., Li, Y., Palaniappan, L. P., Srinivasan, M., Shah, N. S., Wong, S. S., Valero-Elizondo, J., Elfassy, T., Yang, E. 2024: e032509

  Abstract

  Social determinants of health (SDOH) play a significant role in the development of cardiovascular risk factors. We investigated SDOH associations with cardiovascular risk factors among Asian American subgroups.We utilized the National Health Interview Survey, a nationally representative survey of US adults, years 2013 to 2018. SDOH variables were categorized into economic stability, neighborhood and social cohesion, food security, education, and health care utilization. SDOH score was created by categorizing 27 SDOH variables as 0 (favorable) or 1 (unfavorable). Self-reported cardiovascular risk factors included diabetes, high cholesterol, high blood pressure, obesity, insufficient physical activity, suboptimal sleep, and nicotine exposure. Among 6395 Asian adults aged ≥18 years, 22.1% self-identified as Filipino, 21.6% as Asian Indian, 21.0% as Chinese, and 35.3% as other Asian. From multivariable-adjusted logistic regression models, each SD increment of SDOH score was associated with higher odds of diabetes among Chinese (odds ratio [OR], 1.45; 95% CI, 1.04-2.03) and Filipino (OR, 1.24; 95% CI, 1.02-1.51) adults; high blood pressure among Filipino adults (OR, 1.28; 95% CI, 1.03-1.60); insufficient physical activity among Asian Indian (OR, 1.42; 95% CI, 1.22-1.65), Chinese (OR, 1.58; 95% CI, 1.33-1.88), and Filipino (OR, 1.24; 95% CI, 1.06-1.46) adults; suboptimal sleep among Asian Indian adults (OR, 1.20; 95% CI, 1.01-1.42); and nicotine exposure among Chinese (OR, 1.56; 95% CI, 1.15-2.11) and Filipino (OR, 1.50; 95% CI, 1.14-1.97) adults.Unfavorable SDOH are associated with higher odds of cardiovascular risk factors in Asian American subgroups. Culturally specific interventions addressing SDOH may help improve cardiovascular health among Asian Americans.

  View details for DOI 10.1161/JAHA.123.032509

  View details for PubMedID 38567660

• Teaching transgender cultural competency with standardised patients MEDICAL EDUCATION Mukund, A. X., Jia, J. L., Nedelman, M., Rydel, T. A., Bajra, R., Srinivasan, M., Schillinger, E., Laniakea, B. H. 2024

  View details for DOI 10.1111/medu.15325

  View details for Web of Science ID 001161460300001

  View details for PubMedID 38348701

• Participation in a Physician Creative Writing Community: 15‑Year Program Survey Outcomes at an Academic Medical Center Participation in a Physician Creative Writing Community: 15‑Year Program Survey Outcomes at an Academic Medical Center Pien, J., Ali, T., Schlozman, S., Jamaal, A., Bucknor, M., Srinivasan, M. 2024

  View details for DOI 10.1007/s11606-023-08595-5

• Associations Between Ultra-processed Food Consumption and Cardiometabolic Health Among Older US Adults: Comparing Older Asian Americans to Older Adults From Other Major Race-Ethnic Groups. Research on aging Elfassy, T., Juul, F., Mesa, R. A., Palaniappan, L., Srinivasan, M., Yi, S. S. 2023: 1640275231222928

  Abstract

  Using data from the National Health and Nutrition Examination Survey (2001-2018; N = 19,602), this study examined whether ultra-processed food (UPF) consumption is associated with cardiometabolic health (obesity, hypertension, high cholesterol, and diabetes), among White, Black, Hispanic, and Asian Americans (AA) US adults 50 or older. Diet was assessed using 24 hour dietary recall. NOVA dietary classification system was used to calculate the percentage of caloric intake derived from UPFs. Cardiometabolic information was assessed through physical examination, blood tests, and self-reported medication information. A median of 54% (IQR: 40%, 68%) of caloric intake was attributed to UPFs and was lowest for AAs (34%, IQR: 20%, 49%) and highest for White adults (56%; IQR: 42, 69%). In multivariable adjusted models, UPF consumption was associated with greater odds of obesity, high cholesterol, and diabetes. UPF consumption is associated with poor cardiometabolic health among all US older adults. For AAs, UPFs may be particularly obesogenic.

  View details for DOI 10.1177/01640275231222928

  View details for PubMedID 38128550

• Catalyzing System Change: 100 Quality Improvement Projects in 1000 Days. Journal of general internal medicine Sattler, A., Phadke, A., Mickelsen, J., Seay-Morrison, T., Filipowicz, H., Chhoa, D., Srinivasan, M. 2023

  Abstract

  Health system change requires quality improvement (QI) infrastructure that supports frontline staff implementing sustainable innovations. We created an 8-week rapid-cycle QI training program, Stanford Primary Care-Project Engagement Platform (PC-PEP), open to patient-facing primary care clinicians and staff.Examine the feasibility and outcomes of a scalable QI program for busy practicing providers and staff in an academic medical center.Program evaluation.A total of 172 PCPH team members: providers (n = 55), staff (n = 99), and medical learners (n = 18) in the Stanford Division of Primary Care and Population Health (PCPH) clinics, 2018-2021.We categorized projects by the Institute for Healthcare Improvement's (IHI) Quintuple Aim (QA): better health, better patient experience, lower cost of care, better care team experience, and improved equity/inclusion. We assessed project progress with a modified version of The Ottawa Hospital Innovation Framework: step 1 (identified root causes), step 2 (designed/tested interventions), step 3 (assessed project outcome), step 4 (met project goal with target group), step 5A (intervention(s) spread within clinic), step 5B (intervention(s) spread to different setting). Participants rated post-participation QI self-efficacy.Within 1000 days, 172 unique participants completed 104 PC-PEP projects. Most projects aimed to improve patient health (55%) or care team experience (23%). Among projects, 9% reached step 1, 8% step 2, 16% step 3, 26% step 4, 21% step 5A, and 20% step 5B. Learner involvement increased likelihood of scholarly products (47% vs 10%). Forty-six of 47 (98%) survey respondents reported improved QI self-efficacy. Medical assistants, more so than physicians, reported feeling acknowledged by the health system for their QI efforts (100% vs 61%).With appropriate QI infrastructure, scalable QI training models like Stanford PC-PEP can empower frontline workers to create meaningful changes across the IHI QA.

  View details for DOI 10.1007/s11606-023-08431-w

  View details for PubMedID 37985609

  View details for PubMedCentralID 9341176

• COVID-19 pandemic impact on opioid overdose deaths among racial groups within the United States: an observational cross-sectional study. British journal of anaesthesia Chu, R., Sarnala, S., Doan, T., Cheng, T., Chen, A. W., Jamal, A., Kim, G., Huang, R., Srinivasan, M., Palaniappan, L., Gross, E. R. 2023

  View details for DOI 10.1016/j.bja.2023.10.024

  View details for PubMedID 37977954

• Asthma heterogeneity amongst Asian American children: the California Health Interview Survey. Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology Chen, M., Bacong, A. M., Feng, C., Kikuta, N. T., Datir, R. R., Chen, S., Srinivasan, M., Camargo, C. A., Palaniappan, L., Arroyo, A. C. 2023

  Abstract

  The Asian American (AsA) population is heterogenous and rapidly growing; however, little is known regarding childhood asthma burden amongst AsA ethnic groups. The relation of obesity and asthma among AsA ethnic groups also remains unclear.To evaluate asthma prevalence and the relation of obesity to asthma risk amongst children in seven AsA ethnic groups.We analyzed data from the California Health Interview Survey from 2011-2020. AsA ethnicities were self-reported. Body mass index (BMI) z-scores, calculated from self-reported height/weight, were used to categorize children by obesity status, based on BMI-for-age growth charts. Prevalence of self-reported lifetime doctor-diagnosed asthma and asthma attack in the last 12 months were calculated. We performed multivariable logistic regressions adjusting for age and sex.Of 34,146 survey respondents, 12.2% Non-Hispanic White (NHW) and 12.5% AsA children reported lifetime asthma. Among AsA ethnic groups, however, lifetime asthma ranged from 5.1% (Korean American) to 21.5% (Filipino American). Compared to NHW children, AsA children had a similar lifetime asthma prevalence (aOR=1.05; 95%CI: 0.71-1.55; p=0.81), but lower prevalence in Korean American children (aOR 0.37; 95%CI, 0.19-0.73; p=0.004) and higher prevalence in Filipino American children (aOR 1.97; 95%CI, 1.22-3.17; p=0.006). The lifetime asthma prevalence of different AsA ethnic groups persisted even when stratified by obesity status.Childhood lifetime asthma prevalence varied among AsA ethnic groups, with lowest prevalence among Korean American children and highest prevalence among Filipino American. Further characterization of asthma burden amongst AsA ethnic groups may help guide asthma screening and prevention measures and offer new insights into asthma pathogenesis.

  View details for DOI 10.1016/j.anai.2023.10.030

  View details for PubMedID 37949352

• Training future clinicians in telehealth competencies: outcomes of a telehealth curriculum and teleOSCEs at an academic medical center. Frontiers in medicine Bajra, R., Srinivasan, M., Torres, E. C., Rydel, T., Schillinger, E. 2023; 10: 1222181

  Abstract

  This study describes the program and learning outcomes of a telehealth skills curriculum based on the Association of American Medical Colleges (AAMC) telehealth competencies for clerkship-level medical students.A total of 133 third- and fourth-year medical students in a required family medicine clerkship at Stanford University School of Medicine participated in a telehealth curriculum, including a telehealth workshop, site-specific telehealth clinical encounters, and telemedicine objective structured clinical examinations (teleOSCEs) between July 2020 and August 2021. Their workshop communication and physical examination competencies were assessed in two teleOSCEs utilizing a novel telehealth assessment tool. Students' attitudes, skills, and self-efficacy were assessed through voluntary pre-clerkship, post-workshop, and post-OSCE surveys.Most learners reported low confidence in their telehealth physical examinations [n = 79, mean = 1.6 (scale 0-5, 5 = very confident, SD = 1.0)], which improved post-workshop [n = 69, 3.3 (0.9), p < 0.001]; almost all (97%, 70/72) felt the workshop prepared them to see patients in the clinic. In formative OSCEs, learners demonstrated appropriate "webside manner" (communication scores 94-99%, four items) but did not confirm confidentiality (21%) or review limitations of the visit (35%). In a low back pain OSCE, most learners assessed pain location (90%) and range of motion (87%); nearly half (48%) omitted strength testing.Our telehealth curriculum demonstrated that telehealth competencies can be taught and assessed in medical student education. Improvement in self-efficacy scores suggests that an 80-min workshop can prepare students to see patients in the clinical setting. Assessment of OSCE data informs opportunities for growth for further development in the curriculum, including addressing visit limitations and confidentiality in telehealth visits.

  View details for DOI 10.3389/fmed.2023.1222181

  View details for PubMedID 37849494

  View details for PubMedCentralID PMC10577422

• Factors associated with HIV Testing within the National Health Interview Survey (2006-2018). Journal of racial and ethnic health disparities Jamal, A., Srinivasan, M., Kim, G., Nevins, A. B., Vohra, S. 2023

  Abstract

  The Centers for Disease Control and Prevention recommends that individuals aged 13-64 test for HIV at least once during their lifetime. However, screening has been disproportionate among racial/ethnic populations. Using the National Health Interview Survey data (2006-2018), we examined HIV screening prevalence within racial/ethnic groups in the United States (US), and factors associated with testing among 301,191 individuals. This consisted of 195,696 White, 42,409 Black, 47,705 Hispanic and 15,381 Asian individuals. Logistic regression was used to calculate odds ratios (OR) and 95% confidence intervals (CI) to estimate the association between ever testing for HIV and demographic, socioeconomic and health-related factors. Approximately 36% of White, 61% of Black, 47% of Hispanic and 36% of Asian individuals reported ever testing for HIV. Hispanic (OR = 1.28, 95% CI [1.25-1.32]) and Black individuals (OR = 2.44, 95% CI [2.38-2.50]) had higher odds of HIV testing, whereas Asian individuals (OR = 0.74, 95% CI [0.71-0.77]) had lower odds of HIV testing compared to White individuals. Individuals who identified as males, married, between the ages of 18-26 years or greater than or equal to 50 years were less likely to ever test for HIV compared to their counterparts. Similarly, those with lower education, lower income, better self-reported health, no health professional visits or living in the midwestern US were less likely to ever test for HIV compared to their counterparts (OR range: 0.14-0.92). Understanding the factors associated with HIV testing opens opportunities to increase testing rates for all and reduce health disparities in HIV detection.

  View details for DOI 10.1007/s40615-023-01728-w

  View details for PubMedID 37526879

  View details for PubMedCentralID 6994319

• FACTORS ASSOCIATED WITH HIV-TESTING IN THE US POPULATION OVERALL AND BY RACE/ETHNICITY: AN ANALYSIS OF THE 2006-2018 NATIONAL HEALTH INTERVIEW SURVEY Jamal, A., Srinivasan, M., Nevins, A., Kim, G. S., Vohra, S. SPRINGER. 2023: S180-S181

  View details for Web of Science ID 001043057200246

• CATALYZING SYSTEM CHANGE: 100 QUALITY IMPROVEMENT PROJECTS IN 1000 Sattler, A., Phadke, A., Srinivasan, M., Mickelsen, J., Chhoa, D. SPRINGER. 2023: S331-S332

  View details for Web of Science ID 001043057201127

• A QUALITATIVE EVALUATION OF A UNIVERSAL HEPATITIS B SCREENING ELECTRONIC MEDICAL RECORD REMINDER TOOL AT AN ACADEMIC PRIMARY CARE NETWORK Sarnala, S., Chu, R. V., Doan, T. V., Jamal, A., Phadke, A., Hang Pham, So, R., Huang, R., Kim, G. S., Palaniappan, L., Kim, K., Srinivasan, M. SPRINGER. 2023: S329

  View details for Web of Science ID 001043057201121

• SUSTAINING A PHYSICIAN CREATIVE WRITING COMMUNITY: CORE CREATIVE WRITING COMPETENCIES AND LESSONS LEARNED FROM 15 YEARS OF THE PEGASUS PHYSICIAN WRITERS PROGRAM AT STANFORD Pien, J., Schlozman, S., Ali, T. K., Jamaal, A., Bucknor, M., Srinivasan, M. SPRINGER. 2023: S787-S788

  View details for Web of Science ID 001043057203208

• START: A COLLEGIATE PROGRAM TO BRIDGE THE DIGITAL TELEHEALTH DIVIDE Doueiri, Z. N., Bajra, R., Schillinger, E., Srinivasan, M., Cuan, N. L. SPRINGER. 2023: S205

  View details for Web of Science ID 001043057200305

• FACTORS ASSOCIATED WITH HIV TESTING AMONG ASIAN-AMERICANS: AN ANALYSIS OF THE NATIONAL HEALTH INTERVIEW SURVEY Jamal, A., Srinivasan, M., Nevins, A., Kim, G. S., Vohra, S. SPRINGER. 2023: S180

  View details for Web of Science ID 001043057200245

• Why Are We Going Backward? Barriers to Disaggregated Racial Information in Federal Data Sets. American journal of public health Jamal, A., Srinivasan, M., Kim, G., Huang, R. J., Palaniappan, L. 2023: e1-e4

  View details for DOI 10.2105/AJPH.2023.307339

  View details for PubMedID 37319392

• Toward precision sleep medicine: variations in sleep outcomes among disaggregated Asian Americans in the National Health Interview Survey (2006-2018). Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine Wang, R. Z., Jamal, A., Wang, Z., Dan, S., Srinivasan, M., Kim, G., Long, J., Palaniappan, L., Singh, J., Eggert, L. E. 2023

  Abstract

  STUDY OBJECTIVES: Asian Americans (AAs) report higher rates of insufficient sleep than non-Hispanic Whites (NHWs). It is unclear how sleep outcomes differ among disaggregated Asian subgroups.METHODS: The National Health Interview Survey (NHIS) (2006-2018) was used to analyze self-reported sleep duration and quality measures for AA subgroups (Chinese [n=11,056], Asian Indian [n=11,249], Filipino [n = 13,211], and other Asians [n = 21,767]). Outcomes included hours of sleep per day, the number of days reporting trouble falling asleep, staying asleep, waking up rested, and taking sleep medication in the past week. Subsetted multivariate logistic regression was used to assess factors impacting sleep outcomes by ethnicity.RESULTS: 29.2% of NHWs, 26.4% of Chinese, 24.5% of Asian Indians, and 38.4% of Filipinos reported insufficient sleep duration. Filipinos were less likely to report sufficient sleep duration (OR 0.58, [CI95% 0.53-0.63]) and more likely to report trouble falling asleep (1.19, [1.04-1.36]) than NHWs. Chinese and Asian Indians had less trouble staying asleep ((0.66, [0.57-0.76]), (0.50, [0.43-0.58])) and falling asleep ((0.77, [0.67-0.90]), (0.71, [0.61-0.81]) than NHWs, and Asian Indians were more likely to wake feeling well rested (1.71, [1.51-1.92]). All Asian subgroups were less likely to report using sleep medications than NHWs. Foreign-born status had a negative association with sufficient sleep duration in Filipinos, but a positive association in Asian Indians and Chinese.CONCLUSIONS: Filipinos report the highest burden of poor sleep outcomes and Asian Indians report significantly better sleep outcomes. These findings highlight the importance of disaggregating Asian ethnic subgroups to address their health needs.

  View details for DOI 10.5664/jcsm.10558

  View details for PubMedID 36883375

• Disparities and Trends in Routine Adult Vaccination Rates Among Disaggregated Asian American Subgroups, National Health Interview Survey 2006-2018. AJPM focus Wang, Z., Jamal, A., Wang, R., Dan, S., Kappagoda, S., Kim, G., Palaniappan, L., Long, J., Singh, J., Srinivasan, M. 2023; 2 (1): 100044

  Abstract

  Vaccination rates may be improved through culturally tailored messages, but little is known about them among disaggregated Asian American subgroups. We assessed the vaccination rates for key vaccines among these subgroups.Using the National Health Interview Survey, we analyzed recent vaccination rates (2015-2018, n=188,250) and trends (2006-2018) among Asians (Chinese [n=3,165], Asian Indian [n=3,525], Filipino [n=3,656], other Asian [n=5,819]) and non-Hispanic White adults (n=172,085) for 6 vaccines (the human papillomavirus, hepatitis B, pneumococcal, influenza, tetanus-diphtheria [tetanus], and shingles vaccines). We controlled demographic, socioeconomic, and health-related variables in multivariable logistic regression and predicted marginal modeling analyses. We also computed vaccination rates among Asian American subgroups on the 2015-2018 National Health Interview Survey data stratified by foreign-born and U.S.-born status. We used Joinpoint regression to analyze trends in vaccination rates. All analyses were conducted in 2021 and 2022.Among Asians, shingles (29.2%; 95% CI=26.6, 32.0), tetanus (53.7%; 95% CI=51.8, 55.6), and pneumococcal (53.8%; 95% CI=50.1, 57.4) vaccination rates were lower than among non-Hispanic Whites. Influenza (47.9%; 95% CI=46.2, 49.6) and hepatitis B (40.5%; 95% CI=39.0, 42.7) vaccination rates were similar or higher than among non-Hispanic Whites (48.4%; 95% CI=47.9, 48.9 and 30.7%; 95% CI=30.1, 31.3, respectively). Among Asians, we found substantial variations in vaccination rates and trends. For example, Asian Indian women had lower human papillomavirus vaccination rates (12.9%; 95% CI=9.1, 18.0) than all other Asian subgroups (Chinese: 37.9%; 95% CI=31.1, 45.2; Filipinos: 38.7%; 95% CI=29.9, 48.3; other Asians: 30.4%; 95% CI=24.8, 36.7) and non-Hispanic Whites (36.1%; 95% CI=34.8, 37.5). Being male, having lower educational attainment and income, having no health insurance or covered by public health insurance only, and lower frequency of doctor visits were generally associated with lower vaccine uptakes. Foreign-born Asian aggregate had lower vaccination rates than U.S.-born Asian aggregate for all vaccines except for influenza. We also found subgroup-level differences in vaccination rates between foreign-born and U.S.-born Asians. We found that (1) foreign-born Chinese, Asian Indians, and other Asians had lower human papillomavirus and hepatitis B vaccination rates; (2) foreign-born Chinese and Filipinos had lower pneumococcal vaccination rates; (3) foreign-born Chinese and Asian Indians had lower influenza vaccination rates; and (4) all foreign-born Asian subgroups had lower tetanus vaccination rates.Vaccination rates and trends differed among Asian American subgroups. Culturally tailored messaging and interventions may improve vaccine uptakes.

  View details for DOI 10.1016/j.focus.2022.100044

  View details for PubMedID 37789943

  View details for PubMedCentralID PMC10546520

• Association of Acculturation with Cardiovascular Risk Factors in Asian-American Subgroups. American journal of preventive cardiology Li, Y., Zhu, A., LE, A., Singh, J., Palaniappan, L. P., Srinivasan, M., Shah, N. S., Wong, S. S., Elfassy, T., Valero-Elizondo, J., Yang, E. 2023; 13: 100437

  Abstract

  Objective: This cross-sectional study aims to better understand the heterogeneous associations of acculturation level on CV risk factors among disaggregated Asian subgroups. We hypothesize that the association between acculturation level and CV risk factors will differ significantly by Asian subgroup.Methods: We used the National Health Interview Survey (NHIS), a nationally representative US survey, years 2014-18. Acculturation was defined using: (a) years in the US, (b) US citizenship status, and (c) level of English proficiency. We created an acculturation index, categorized into low vs. high (scores of 0-3 and 4, respectively). Self-reported CV risk factors included diabetes, high cholesterol, hypertension, obesity, tobacco use, and sufficient physical activity. Rao-Scott Chi Square was used to compare age-standardized, weighted prevalence of CV risk factors between Asian subgroups. We used logistic regression analysis to assess associations between acculturation and CV risk factors, stratified by Asian subgroup.Results: The study sample consisted of 6,051 adults ≥ 18 years of age (53.9% female; mean age 46.6 [SE 0.33]). The distribution by race/ethnicity was Asian Indian 26.9%, Chinese 22.8%, Filipino 18.1%, and other Asian 32.3%. The association between acculturation and CV risk factors differed by Asian subgroups. From multivariable adjusted models, high vs. low acculturation was associated with: high cholesterol amongst Asian Indian (OR=1.57, 95% CI: 1.11, 2.37) and other Asian (OR=1.48, 95% CI: 1.10, 2.01) adults, obesity amongst Filipino adults (OR= 1.62, 95% CI: 1.07, 2.45), and sufficient physical activity amongst Chinese (OR= 1.54, 95% CI: 1.09, 2.19) and Filipino adults (OR=1.58, 95% CI: 1.10, 2.27).Conclusion: This study demonstrates that acculturation is heterogeneously associated with higher prevalence of CV risk factors among Asian subgroups. More studies are needed to better understand these differences that can help to inform targeted, culturally specific interventions.

  View details for DOI 10.1016/j.ajpc.2022.100437

  View details for PubMedID 36545389

• Asthma heterogeneity amongst Asian American children: the California Health Interview Survey Chen, M., Bacong, A., Kikuta, N., Datir, R., Chen, S., Camargo, C., Srinivasan, M., Palaniappan, L., Arroyo, A. MOSBY-ELSEVIER. 2023: AB75

  View details for Web of Science ID 000991651900228

• 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

• Impact of US Opioid Drug Overdose by Race/Ethnicity and State in 2005-2017 Zhu, A., Li, Y., Le, A., Xu, J., Singh, J., Srinivasan, M., Palaniappan, L. P., Long, J., Gross, E. R. LIPPINCOTT WILLIAMS & WILKINS. 2022: 712-714

  View details for Web of Science ID 000840283000286

• 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. 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

• 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 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

• Leading causes of death in Asian Indians in the United States (2005-2017). PloS one Fernandez Perez, C., Xi, K., Simha, A., Shah, N. S., Huang, R. J., Palaniappan, L., Chung, S., Au, T., Sharp, N., Islas, N., Srinivasan, M. 2022; 17 (8): e0271375

  Abstract

  OBJECTIVE: Asian Indians are among the fastest growing United States (US) ethnic subgroups. We characterized mortality trends for leading causes of death among foreign-born and US-born Asian Indians in the US between 2005-2017.STUDY DESIGN AND SETTING: Using US standardized death certificate data, we examined leading causes of death in 73,470 Asian Indians and 20,496,189 non-Hispanic whites (NHWs) across age, gender, and nativity. For each cause, we report age-standardized mortality rates (AMR), longitudinal trends, and absolute percent change (APC).RESULTS: We found that Asian Indians' leading causes of death were heart disease (28% mortality males; 24% females) and cancer (18% males; 22% females). Foreign-born Asian Indians had higher all-cause AMR compared to US-born (AMR 271 foreign-born, CI 263-280; 175.8 US-born, CI 140-221; p<0.05), while Asian Indian all-cause AMR was lower than that of NHWs (AMR 271 Indian, CI 263-278; 754.4 NHW, CI 753.3-755.5; p<0.05). All-cause AMR increased for foreign-born Asian Indians over time, while decreasing for US-born Asian Indians and NHWs.CONCLUSIONS: Foreign-born Asian Indians were 2.2 times more likely to die of heart disease and 1.6 times more likely to die of cancer. Asian Indian male AMR was 49% greater than female on average, although AMR was consistently lower for Asian Indians when compared to NHWs.

  View details for DOI 10.1371/journal.pone.0271375

  View details for PubMedID 35947608

• 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

• Achieving Equity in Asian American Healthcare: Critical Issues and Solutions. Journal of Asian health Obra, J. K., Lin, B., Đoàn, L. N., Palaniappan, L., Srinivasan, M. 2021; 1 (1)

  Abstract

  Equity is a fundamental goal of the US health care system. Asians comprise 6% of the US population, and 60% of the world's population. Less than 1% of National Institutes of Health funding is directed toward Asian health. Asian health outcomes are often worse than non-Hispanic Whites (NHWS) in America. Increasing federal and foundation resources and funding toward Asian health research could illuminate these risks and develop precision interventions to reduce known health disparities. When disaggregated by race/ethnicity, Asian health risks are even more apparent. Here, we discuss critical health outcome differences between the six major Asian American subgroups (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) comprising 80% of the US Asian population, highlighting demographic, pharmacologic, disease prevalence, and mortality outcomes. We then outline seven critical issues contributing to Asian American health disparities, including aggregated Asian health data, undersampling, invalid extrapolations, underrepresentation in clinical trials, lack of funding and awareness of disparities, and the model minority myth. Building on the successes of national public health initiatives, we propose nine leverage points to improve Asian American health including the following: obtaining disaggregated Asian health data, improved Asian health research (oversampling Asians, improving clinical trial participation, and increasing research funding), stakeholder collaboration (national and with Asian nations), community engagement, providing culturally precise health care, and expansion of the Asian American research ecosystem. Achieving health equity takes deliberate practice and does not occur by accident. By addressing critical issues that perpetuate Asian health disparities, we grow closer to understanding how to effectively improve Asian health and build a nationally unified mindset toward action that emphasizes equitable care for all.

  View details for DOI 10.59448/jah.v1i1.3

  View details for PubMedID 37872960

  View details for PubMedCentralID PMC10593109

• 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

• ASSOCIATIONS BETWEEN ULTRA-PROCESSED FOOD INTAKE AND CARDIOMETABOLIC HEALTH AMONG DIVERSE US ADULTS 50 OR OLDER Elfassy, T., Juul, F., Mesa, R., Palaniappan, L., Srinivasan, M., Yi, S. OXFORD UNIV PRESS. 2021: 51

  View details for Web of Science ID 000842009900198

• 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

• "Teaching as a Competency": Competencies for Medical Educators ACADEMIC MEDICINE Srinivasan, M., Li, S. T., Meyers, F. J., Pratt, D. D., Collins, J. B., Braddock, C., Skeff, K. M., West, D. C., Henderson, M., Hales, R. E., Hilty, D. M. 2011; 86 (10): 1211-1220

  Abstract

  Most medical faculty receive little or no training about how to be effective teachers, even when they assume major educational leadership roles. To identify the competencies required of an effective teacher in medical education, the authors developed a comprehensive conceptual model. After conducting a literature search, the authors met at a two-day conference (2006) with 16 medical and nonmedical educators from 10 different U.S. and Canadian organizations and developed an initial draft of the "Teaching as a Competency" conceptual model. Conference participants used the physician competencies (from the Accreditation Council for Graduate Medical Education [ACGME]) and the roles (from the Royal College's Canadian Medical Education Directives for Specialists [CanMEDS]) to define critical skills for medical educators. The authors then refined this initial framework through national/regional conference presentations (2007, 2008), an additional literature review, and expert input. Four core values grounded this framework: learner engagement, learner-centeredness, adaptability, and self-reflection. The authors identified six core competencies, based on the ACGME competencies framework: medical (or content) knowledge; learner- centeredness; interpersonal and communication skills; professionalism and role modeling; practice-based reflection; and systems-based practice. They also included four specialized competencies for educators with additional programmatic roles: program design/implementation, evaluation/scholarship, leadership, and mentorship. The authors then cross-referenced the competencies with educator roles, drawing from CanMEDS, to recognize role-specific skills. The authors have explored their framework's strengths, limitations, and applications, which include targeted faculty development, evaluation, and resource allocation. The Teaching as a Competency framework promotes a culture of effective teaching and learning.

  View details for DOI 10.1097/ACM.0b013e31822c5b9a

  View details for Web of Science ID 000295357000017

  View details for PubMedID 21869655

• The validity of peer review in a general medicine journal. PloS one Jackson, J. L., Srinivasan, M., Rea, J., Fletcher, K. E., Kravitz, R. L. 2011; 6 (7): e22475

  Abstract

  All the opinions in this article are those of the authors and should not be construed to reflect, in any way, those of the Department of Veterans Affairs.Our study purpose was to assess the predictive validity of reviewer quality ratings and editorial decisions in a general medicine journal.Submissions to the Journal of General Internal Medicine (JGIM) between July 2004 and June 2005 were included. We abstracted JGIM peer review quality ratings, verified the publication status of all articles and calculated an impact factor for published articles (Rw) by dividing the 3-year citation rate by the average for this group of papers; an Rw>1 indicates a greater than average impact.Of 507 submissions, 128 (25%) were published in JGIM, 331 rejected (128 with review) and 48 were either not resubmitted after revision was requested or were withdrawn by the author. Of 331 rejections, 243 were published elsewhere. Articles published in JGIM had a higher citation rate than those published elsewhere (Rw: 1.6 vs. 1.1, p = 0.002). Reviewer quality ratings of article quality had good internal consistency and reviewer recommendations markedly influenced publication decisions. There was no quality rating cutpoint that accurately distinguished high from low impact articles. There was a stepwise increase in Rw for articles rejected without review, rejected after review or accepted by JGIM (Rw 0.60 vs. 0.87 vs. 1.56, p<0.0005). However, there was low agreement between reviewers for quality ratings and publication recommendations. The editorial publication decision accurately discriminated high and low impact articles in 68% of submissions. We found evidence of better accuracy with a greater number of reviewers.The peer review process largely succeeds in selecting high impact articles and dispatching lower impact ones, but the process is far from perfect. While the inter-rater reliability between individual reviewers is low, the accuracy of sorting is improved with a greater number of reviewers.

  View details for DOI 10.1371/journal.pone.0022475

  View details for PubMedID 21799867

  View details for PubMedCentralID PMC3143147

• 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

• Impact of student ethnicity and patient-centredness on communication skills performance MEDICAL EDUCATION Hauer, K. E., Boscardin, C., Gesundheit, N., Nevins, A., Srinivasan, M., Fernandez, A. 2010; 44 (7): 653-661

  Abstract

  The development of patient-centred attitudes by health care providers is critical to improving health care quality. A prior study showed that medical students with more patient-centred attitudes scored higher in communication skills as judged by standardised patients (SPs) than students with less patient-centred attitudes. We designed this multicentre study to examine the relationships among students' demographic characteristics, patient-centredness and communication scores on an SP examination.Early Year 4 medical students at three US schools completed a 12-item survey during an SP examination. Survey items addressed demographics (gender, ethnicity, primary childhood language) and patient-centredness. Factor analysis on the patient-centredness items defined specific patient-centred attitudes. We used multiple regression analysis incorporating demographic characteristics, school and patient-centredness items and examined the effect of these variables on the outcome variable of communication score.A total of 351 students took the SP examination and 329 (94%) completed the patient-centredness questionnaire. Responses indicated generally high patient-centredness. Student ethnicity and medical school were significantly associated with communication scores; gender and primary childhood language were not. Two attitudinal factors were identified: patient perspective and impersonal attitude. Multiple regression analysis revealed that school and scores on the impersonal factor were associated with communication scores. The effect size was modest.In a medical student SP examination, modest differences in communication scores based on ethnicity were observed and can be partially explained by student attitudes regarding patient-centredness. Curricular interventions to enhance clinical experiences, teaching and feedback are needed to address key elements of a patient-centred approach to care.

  View details for DOI 10.1111/j.1365-2923.2010.03632.x

  View details for Web of Science ID 000278928700005

  View details for PubMedID 20636584

• 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

• "teaching as a competency" for medical educators: Results of a multidisciplinary medical educator conference Srinivasan, M., Hilty, D. M., Pratt, D. D., Collins, J., Braddock, C. H., Skeff, K. M., West, D. C., Hales, R. E., Meyers, F. J. SPRINGER. 2008: 191

  View details for Web of Science ID 000254237100282

• End-of-Life care: guidelines for patient-centered communication. American family physician Ngo-Metzger, Q., August, K. J., Srinivasan, M., Liao, S., Meyskens, F. L. 2008; 77 (2): 167-74

  Abstract

  When patients are diagnosed with cancer, primary care physicians often must deliver the bad news, discuss the prognosis, and make appropriate referrals. When delivering bad news, it is important to prioritize the key points that the patient should retain. Physicians should assess the patient's emotional state, readiness to engage in the discussion, and level of understanding about the condition. The discussion should be tailored according to these assessments. Often, multiple visits are needed. When discussing prognosis, physicians should be sensitive to variations in how much information patients want to know. The challenge for physicians is to communicate prognosis accurately without giving false hope. All physicians involved in the patient's care should coordinate their key prognosis points to avoid giving the patient mixed messages. As the disease progresses, physicians must reassess treatment effectiveness and discuss the values, goals, and preferences of the patient and family. It is important to initiate conversations about palliative care early in the disease course when the patient is still feeling well. There are innovative hospice programs that allow for simultaneous curative and palliative care. When physicians discuss the transition from curative to palliative care, they should avoid phrases that may convey to the patient a sense of failure or abandonment. Physicians also must be cognizant of how cultural factors may affect end-of-life discussions. Sensitivity to a patient's cultural and individual preferences will help the physician avoid stereotyping and making incorrect assumptions.

  View details for PubMedID 18246886

• 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

• Electronic medical records and their impact on resident and medical student education (vol 30, pg 522, 2006) ACADEMIC PSYCHIATRY Keenan, C. R., Nguyen, H. H., Srinivasan, M. 2007; 31 (6): 492

  View details for Web of Science ID 000251787400015

• 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

• Ratings of physician communication by real and standardized patients. Annals of family medicine Fiscella, K., Franks, P., Srinivasan, M., Kravitz, R. L., Epstein, R. 2007; 5 (2): 151-8

  Abstract

  Patient ratings of physician's patient-centered communication are used by various specialty credentialing organizations and managed care organizations as a measure of physician communication skills. We wanted to compare ratings by real patients with ratings by standardized patients of physician communication.We assessed physician communication using a modified version of the Health Care Climate Questionnaire (HCCQ) among a sample of 100 community physicians. The HCCQ measures physician autonomy support, a key dimension in patient-centered communication. For each physician, the questionnaire was completed by roughly 49 real patients and 2 unannounced standardized patients. Standardized patients portrayed 2 roles: gastroesophageal disorder reflux symptoms and poorly characterized chest pain with multiple unexplained symptoms. We compared the distribution, reliability, and physician rank derived from using real and standardized patients after adjusting for patient, physician, and standardized patient effects.There were real and standardized patient ratings for 96 of the 100 physicians. Compared with standardized patient scores, real-patient-derived HCCQ scores were higher (mean 22.0 vs 17.2), standard deviations were lower (3.1 vs 4.9), and ranges were similar (both 5-25). Calculated real patient reliability, given 49 ratings per physician, was 0.78 (95% confidence interval [CI], 0.71-0.84) compared with the standardized patient reliability of 0.57 (95% CI, 0.39-0.73), given 2 ratings per physician. Spearman rank correlation between mean real patient and standardized patient scores was positive but small to moderate in magnitude, 0.28.Real patient and standardized patient ratings of physician communication style differ substantially and appear to provide different information about physicians' communication style.

  View details for DOI 10.1370/afm.643

  View details for PubMedID 17389540

  View details for PubMedCentralID PMC1838677

• 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

• Saving time, improving satisfaction: the impact of a digital radiology system on physician workflow and system efficiency Journal of Healthcare Information Management Srinivasan, M. 2006; 20 (2)
• 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

• Patient desires: a model for assessment of patient preferences for care of severe or terminal illness Palliative & Supportive Care Knops, K. 2005; 3 (4)
• 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

• Medicare financing of graduate medical education. Journal of general internal medicine Rich, E. C., Liebow, M., Srinivasan, M., Parish, D., Wolliscroft, J. O., Fein, O., Blaser, R. 2002; 17 (4): 283-92

  Abstract

  The past decade has seen ongoing debate regarding federal support of graduate medical education, with numerous proposals for reform. Several critical problems with the current mechanism are evident on reviewing graduate medical education (GME) funding issues from the perspectives of key stakeholders. These problems include the following: substantial interinstitutional and interspecialty variations in per-resident payment amounts; teaching costs that have not been recalibrated since 1983; no consistent control by physician educators over direct medical education (DME) funds; and institutional DME payments unrelated to actual expenditures for resident education or to program outcomes. None of the current GME reform proposals adequately address all of these issues. Accordingly, we recommend several fundamental changes in Medicare GME support. We propose a re-analysis of the true direct costs of resident training (with appropriate adjustment for local market factors) to rectify the myriad problems with per-resident payments. We propose that Medicare DME funds go to the physician organization providing resident instruction, keeping DME payments separate from the operating revenues of teaching hospitals. To ensure financial accountability, we propose that institutions must maintain budgets and report expenditures for each GME program. To establish educational accountability, Residency Review Committees should establish objective, annually measurable standards for GME program performance; programs that consistently fail to meet these minimum standards should lose discretion over GME funds. These reforms will solve several long-standing, vexing problems in Medicare GME funding, but will also uncover the extent of undersupport of GME by most other health care payers. Ultimately, successful reform of GME financing will require "all-payer" support.

  View details for DOI 10.1046/j.1525-1497.2002.10804.x

  View details for PubMedID 11972725

  View details for PubMedCentralID PMC1495035

• 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

• Cigarette smoke and asbestos activate poly-ADP-ribose polymerase in alveolar epithelial cells. Journal of investigative medicine : the official publication of the American Federation for Clinical Research Kamp, D. W., Srinivasan, M., Weitzman, S. A. 2001; 49 (1): 68-76

  Abstract

  Cigarette smoke augments asbestos-induced bronchogenic carcinoma in a synergistic manner by mechanisms that are not established. One important mechanism may involve alveolar epithelial cell (AEC) injury resulting from oxidant-induced DNA damage that subsequently activates poly (ADP-ribose) polymerase (PARP), an enzyme involved in DNA repair that can deplete cellular energy stores. We previously showed that whole aqueous cigarette smoke extracts (CSE) augment amosite asbestos-induced DNA damage and cytotoxicity to cultured AEC in part by generating iron-induced free radicals. We hypothesized that CSE increase asbestos-induced AEC injury by triggering PARP activation resulting from DNA damage caused by iron-induced free radicals.Aqueous CSE were prepared fresh on the day of each experiment. PARP activity in WI-26 (a type I-like cell line) and A549 (a type II-like cell line) cells was assessed by the uptake of labeled NAD over 4 hours and confirmed on the basis of the reduction of PARP levels in the presence of a PARP inhibitor, 3-aminobenzamide (3-ABA). Cell survival was assessed by trypan blue dye exclusion.Hydrogen peroxide (H2O2; 1-250 microM), CSE (0.4-10 vol%), and amosite asbestos (5-250 micrograms/cm2) each caused PARP activation in WI-26 and A549 cells. The combination of asbestos (5 micrograms/cm2) and CSE (0.04-10%) induced WI-26 and A549 cell PARP activation without evidence of synergism. 3-ABA significantly attenuated WI-26 and A549 cell PARP activity and cell death after exposure to H2O2, CSE, and asbestos. Phytic acid, an iron chelator, catalase, and superoxide dismutase each decreased WI-26 cell PARP activation caused by asbestos and CSE.CSE and asbestos induced PARP activation in cultured AEC in a nonsynergistic manner. These data provide further support that asbestos and cigarette smoke are genotoxic to relevant lung target cells and that iron-induced free radicals in part cause these effects.

  View details for DOI 10.2310/6650.2001.34092

  View details for PubMedID 11217149

• 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