Clinical Professor, Medicine - Primary Care and Population Health
Medical Director, Patient Centered Care, Primary Care, Stanford (2013 - 2016)
Associate Director, Stanford Geriatric Education Center (2007 - 2015)
Co-Director, Stanford Geriatric Education Center (2002 - 2006)
Clinic Chief, Stanford Family Medicine (1998 - 2013)
Honors & Awards
Stanford HealthCare Physician of the Year, 2022, Stanford HealthCare (2022)
Dr. Augustus A. White and Family Faculty Professionalism Award., Stanford University School of Medicine (2018)
Invited Participant, The Lown Institute Conference, "From Avoidable Care to Right Care" (2013)
Invited Participant, Stanford Physician/Faculty Advanced Leadership Development Program (2012)
Leadership Fellow, California HealthCare Foundation Leadership Fellowship (2008-2010)
Invited Participant, Stanford Physician Leadership Development Program (2006-2007)
Standard Setting Committee for Examination, 2005. American Board of Family Medicine., American Board of Family Medicine (2005)
Named as one of the "Best Doctors", Best Doctors (2003 to present)
Song Brown Fellowship in Family Medicine, Stanford Affiliated Family Practice Residency at San Jose Hospital (1984-1985)
Boards, Advisory Committees, Professional Organizations
Ad Hoc Study Section Member, Health Care Research Training, AHRQ (2014 - 2016)
Ad Hoc Study Section Member, Accelerating the Dissemination and Implementation of PCOR Findings into Primary Care Practice, AHRQ (2014 - 2014)
Invited Mentor, Stanford School of Medicine Faculty Fellows Leadership Program (2013 - 2014)
Study Section Member, Health Care Quality and Effectiveness Research, AHRQ (2010 - 2014)
Member, National Working Group, ³Promoting Good Stewardship in Clinical Practice² National Physicians' Alliance (2009 - 2010)
Ad Hoc Study Section Member, Special Emphasis Panel RFA 10-002 for “Transforming Primary Care Practice", AHRQ (2010 - 2010)
Vice-chair, Appointment and Promotion Committee for Clinician Educators, Stanford University School of Medicine. (2007 - 2014)
Fellow, American Academy of Family Physicians (1985 - Present)
M.P.H., University of Hawaii/UC Berkeley, Health Planning and Policy (1985)
M.D., University of Hawaii (1981)
B.S., Stanford University, Biology (1976)
Current Research and Scholarly Interests
My research is directed towards decreasing the gap between health care demand and supply. On the demand side, I work to empower communities to be healthy. On the supply side, I try to increase access to behavioral health resources for depressed older adults and to prevent burnout among health care providers.
Stanford Youth Diabetes Coaches Program (SYDCP)
Over the past 13 years since I started SYDCP, it has gained nationwide prominence as an evidence-based training program that improves the teen participants’ health knowledge, behaviors and self-assets. In 2021, it was selected to be included in the national “toolkit” programs by SNAP-Ed, the education program associated with what was formerly known as the “food stamp” program. Active in settings across the country, SYDCP provides the curriculum and help with implementation to its many community partners including Area Health Education Centers, Family Medicine residency programs, and public high schools in under served areas of the country.
In 2023, our focus is on implementation and dissemination research. We have new community partners in the Central Valley of California, under resourced communities on Oahu, Hawaii, and the Mississippi Delta. None rely on us for any operational costs. Rather, we provide program evaluation to demonstrate the “return on investment” for communities that partner with us. Understanding this helps programs to be sustainable.
PEP (Positive Experience Program) for Depressed Older Adults
At the beginning of the pandemic, colleagues and I developed a program in which primary care providers (PCPs) could help depressed older adults with brief behavioral activation therapy. This evidence based behavioral approach to treating depression in the elderly has been shown to be better than medication. The reason that it is not generally available is that historically it has required weekly 90-minute sessions for at least 10 weeks with a therapist. In PEP, we have created "scripts" that PCPs can read during a series of three weekly 30-minute standard patient care visits. The pilot studies showed that the elderly patients benefited from this and that most were no longer depressed after the three sessions of treatment. An unexpected outcome was that participating providers enjoyed these visits with their patients and found them easy to complete. This has tremendous potential to help the increasing numbers of depressed older adults who currently have no access to behavioral mental health care.
ASCEND (Acts of Self Compassion ExperieNced Daily)
There is a mental health crisis among health care professionals (HCPs). Self-compassion training has been taught to HCPs and found to be effective at improving quality of life, burnout components of emotional exhaustion and personal accomplishment and at reducing clinical stress. Despite its benefits, HCPs may not attend self-compassion training that is offered and even after being trained, may not practice self-compassion. We aim to learn more about how to increase the number of HCPs who practice self-compassion on a regular basis.
Independent Studies (5)
- Directed Reading in Medicine
MED 299 (Aut, Win, Spr)
- Early Clinical Experience in Medicine
MED 280 (Win, Spr)
- Graduate Research
MED 399 (Aut, Win, Spr)
- Medical Scholars Research
MED 370 (Aut, Win, Spr)
- Undergraduate Research
MED 199 (Aut, Win, Spr)
- Directed Reading in Medicine
Remote Implementation of a School-Based Health Promotion and Health Coaching Program in Low-Income Urban and Rural Sites: Program Impact during the COVID-19 Pandemic.
International journal of environmental research and public health
2023; 20 (2)
Adapting existing health programs for synchronous remote implementation has the potential to support vulnerable youth during the COVID 19 pandemic and beyond.The Stanford Youth Diabetes Coaches Program (SYDCP), a school-based health promotion and coaching skills program, was adapted for remote implementation and offered to adolescents from low-income communities in the US: an urban site in San Jose, CA and rural sites in Lawrence County, MO, and Central Valley, CA. Participants completed online pre- and post- surveys. Analysis included paired T-tests, linear regression, and qualitative coding.Of 156 enrolled students, 100 completed pre- and post-surveys. Of those: 84% female; 40% Hispanic; 37% White; 28% Asian; 3% African American; 30% other race. With T-tests and regression models, the following measures showed statistically significant improvements after program participation: health knowledge, patient activation, health understanding and communication, consumption of fruits and vegetables, psychosocial assets of self-esteem, self-efficacy, problem-solving, and ability to reduce stress. Technology barriers were frequently reported at Lawrence County site. 96% participants reported making a lifestyle change after program participation.Remote implementation of health promotion programs for vulnerable youth in diverse settings has potential to support adoption of healthy behaviors, enhance patient activation levels, and improve psychosocial assets.
View details for DOI 10.3390/ijerph20021044
View details for PubMedID 36673800
PILOT STUDY OF A NEW TELEHEALTH PROGRAM FOR DEPRESSED OLDER ADULTS: THE POSITIVE EXPERIENCE PROJECT (PEP)
OXFORD UNIV PRESS. 2021: 631
View details for Web of Science ID 000842009903093
- Remote Implementation of a Health Promotion Program in an Underserved High School during COVID-19: Lessons Learned J Pediatr & Child Health Care 2021; 6 (2)
Increasing patient activation scores of vulnerable youth by partnering medical residency programs with public high schools.
Patient education and counseling
To assess whether participation in Stanford Youth Coaches Programs (SYCP) increases patient activation scores and patient activation levels for vulnerable youth from low income communities.From 2016 to 18, seven high schools and four residency programs in California, Alabama, Kansas and Missouri participated in SYCPs. Enrolled youth participants completed online pre and post-participation surveys including the Patient Activation Measure (PAM®10). We used paired T-tests, chi square tests, and linear multivariate models to compare pre-and post-scores and levels.143 participants completed pre- and post-participation surveys. The PAM®10 mean pre-test score was 64.5 and post-test was 69.37, with mean difference 4.89 (p=.002). Participants showed significant improvement in patient activation levels after participation. 60 % participants in lowest activation Level 1; 63 % in Level 2; and 32 % in Level 3 moved to a higher level of activation after participation; 46 % who started in Level 4 moved down to Level 3 after participation.Participation in SYCPs has potential to significantly increase patient activation for vulnerable youth which could lead to lifelong improvements in health outcomes and decrease in healthcare costs.
View details for DOI 10.1016/j.pec.2020.08.035
View details for PubMedID 32948399
- Addressing Health Disparities and Increasing Cultural Competency of Medical Trainees with Community Engagement J Community Med Health Educ 2019; 9 (1): 647
Association of Electronic Health Record Design and Use Factors With Clinician Stress and Burnout.
JAMA network open
2019; 2 (8): e199609
Many believe a major cause of the epidemic of clinician burnout is poorly designed electronic health records (EHRs).To determine which EHR design and use factors are associated with clinician stress and burnout and to identify other sources that contribute to this problem.This survey study of 282 ambulatory primary care and subspecialty clinicians from 3 institutions measured stress and burnout, opinions on EHR design and use factors, and helpful coping strategies. Linear and logistic regressions were used to estimate associations of work conditions with stress on a continuous scale and burnout as a binary outcome from an ordered categorical scale. The survey was conducted between August 2016 and July 2017, with data analyzed from January 2019 to May 2019.Clinician stress and burnout as measured with validated questions, the EHR design and use factors identified by clinicians as most associated with stress and burnout, and measures of clinician working conditions.Of 640 clinicians, 282 (44.1%) responded. Of these, 241 (85.5%) were physicians, 160 (56.7%) were women, and 193 (68.4%) worked in primary care. The most prevalent concerns about EHR design and use were excessive data entry requirements (245 [86.9%]), long cut-and-pasted notes (212 [75.2%]), inaccessibility of information from multiple institutions (206 [73.1%]), notes geared toward billing (206 [73.1%]), interference with work-life balance (178 [63.1%]), and problems with posture (144 [51.1%]) and pain (134 [47.5%]) attributed to the use of EHRs. Overall, EHR design and use factors accounted for 12.5% of variance in measures of stress and 6.8% of variance in measures of burnout. Work conditions, including EHR use and design factors, accounted for 58.1% of variance in stress; key work conditions were office atmospheres (β̂ = 1.26; P < .001), control of workload (for optimal control: β̂ = -7.86; P < .001), and physical symptoms attributed to EHR use (β̂ = 1.29; P < .001). Work conditions accounted for 36.2% of variance in burnout, where challenges included chaos (adjusted odds ratio, 1.39; 95% CI, 1.10-1.75; P = .006) and physical symptoms perceived to be from EHR use (adjusted odds ratio, 2.01; 95% CI, 1.48-2.74; P < .001). Coping strategies were associated with only 2.4% of the variability in stress and 1.7% of the variability in burnout.Although EHR design and use factors are associated with clinician stress and burnout, other challenges, such as chaotic clinic atmospheres and workload control, explain considerably more of the variance in these adverse clinician outcomes.
View details for DOI 10.1001/jamanetworkopen.2019.9609
View details for PubMedID 31418810
The electronic elephant in the room: Physicians and the electronic health record
2018; 1 (1): 49-56
View details for DOI 10.1093/jamiaopen/ooy016
Supporting At-Risk Youth and Their Families to Manage and Prevent Diabetes: Developing a National Partnership of Medical Residency Programs and High Schools
2016; 11 (7)
The Stanford Youth Diabetes Coaches Program (SYDCP) is a school based health program in which Family Medicine residents train healthy at-risk adolescents to become diabetes self-management coaches for family members with diabetes. This study evaluates the impact of the SYDCP when disseminated to remote sites. Additionally, this study aims to assess perceived benefit of enhanced curriculum.From 2012-2015, 10 high schools and one summer camp in the US and Canada and five residency programs were selected to participate. Physicians and other health providers implemented the SYDCP with racial/ethnic-minority students from low-income communities. Student coaches completed pre- and posttest surveys which included knowledge, health behavior, and psychosocial asset questions (i.e., worth and resilience), as well as open-ended feedback questions. T-test pre-post comparisons were used to determine differences in knowledge and psychosocial assets, and open and axial coding methods were used to analyze qualitative data.A total of 216 participating high school students completed both pre-and posttests, and 96 nonparticipating students also completed pre- and posttests. Student coaches improved from pre- to posttest significantly on knowledge (p<0.005 in 2012-13, 2014 camp, and 2014-15); worth (p<0.1 in 2014-15); problem solving (p<0.005 in 2014 camp and p<0.1 in 2014-15); and self-efficacy (p<0.05 in 2014 camp). Eighty-two percent of student coaches reported that they considered making a behavior change to improve their own health as a result of program participation. Qualitative feedback themes included acknowledgment of usefulness and relevance of the program, appreciation for physician instructors, knowledge gain, pride in helping family members, improved relationships and connectedness with family members, and lifestyle improvements.Overall, when disseminated, this program can increase health knowledge and some psychosocial assets of at-risk youth and holds promise to empower these youth with health literacy and encourage them to adopt healthy behaviors.
View details for DOI 10.1371/journal.pone.0158477
View details for Web of Science ID 000379809400051
View details for PubMedID 27383902
View details for PubMedCentralID PMC4934855
Service-Based Learning for Residents: A Success for Communities and Medical Education.
2015; 47 (10): 803-806
Community-based service-learning opportunities could support residents' acquisition of Accreditation Council for Graduate Medical Education (ACGME) competencies, but this concept has not been tested, and such programs are difficult to find. The objective of this work was to assess the value and the ACGME competency relevance of a service-learning program for residents that could be easily replicated nationally.Forty-one family medicine residents from three training programs participated in the Stanford Youth Diabetes Coaches Program at six high schools in California and Georgia serving minority students of low socioeconomic status. Residents completed online surveys to provide qualitative feedback and assess the program's impact on their acquisition of residency program competencies and self-management support proficiencies, including prior use and planned use of action plans-a key self-management support strategy.Ninety-five percent of residents indicated that the program was a valuable experience that contributed to acquisition of residency program competencies, including interpersonal and communication skills and communication with teens. Compared with baseline, significantly more residents reported intention to use action plans with patients following participation. Themes from qualitative feedback included: valuing the overall experience, increasing opportunities to practice teaching, enhancing their ability to communicate with adolescents, contributing to the health of the community, recognizing the potential of action plans, and increasing intent to use action plans.This pilot demonstrated that a brief service-learning program can enhance standard residency curriculum by encouraging acquisition of ACGME competencies and promoting utilization of self-management support in clinical practice.
View details for PubMedID 26545059
Training at-risk youth to become diabetes self-management coaches for family members: partnering family medicine residents with underserved schools.
2014; 40 (6): 786-796
The purpose of this study is to evaluate the impact of a school-based health program in which family medicine residents trained healthy at-risk adolescents to become diabetes self-management coaches for family members with diabetes.A mixed methods study included 97 adolescents from 3 San Francisco Bay Area high schools serving primarily ethnic minority youth of low socioeconomic status. Physicians came to schools once a week for 8 weeks and trained 49 adolescents to become coaches. Student coaches and 48 nonparticipant students completed pre- and posttest intervention questionnaires, and 15 student coaches and 9 family members with diabetes gave in-depth interviews after participation. Linear regression was used to determine differences in knowledge and psychosocial assets on pre- and posttests between student coaches and nonparticipant students, and NVIVO was used to analyze interview transcripts.After controlling for initial score, sex, grade, and ethnicity, student coaches improved from pre- to posttest significantly compared to nonparticipants on knowledge, belonging, and worth scales. Student coaches reported high satisfaction with the program. Articulated program benefits included improvement in diet, increased physical activity, and improved relationship between student coach and family member.Overall, this program can increase diabetes knowledge and psychosocial assets of at-risk youth, and it holds promise to promote positive health behaviors among at-risk youth and their families.
View details for DOI 10.1177/0145721714549676
View details for PubMedID 25208725
No Papanicolaou tests in women younger than 21 years or after hysterectomy for benign disease.
JAMA internal medicine
2013; 173 (10): 855-856
View details for DOI 10.1001/jamainternmed.2013.316
View details for PubMedID 23568165
The "Top 5" Lists in Primary Care Meeting the Responsibility of Professionalism
ARCHIVES OF INTERNAL MEDICINE
2011; 171 (15): 1385-1390
Physicians can adhere to the principles of professionalism by practicing high-quality, evidence-based care and advocating for just and cost-effective distribution of finite clinical resources. To promote these principles, the National Physicians Alliance (NPA) initiated a project titled "Promoting Good Stewardship in Clinical Practice" that aimed to develop a list of the top 5 activities in family medicine, internal medicine, and pediatrics where the quality of care could be improved.Working groups of NPA members in each of the 3 primary care specialties agreed that an ideal activity would be one that was common in primary care practice, that was strongly supported by the evidence, and that would lead to significant health benefits and reduce risks, harms, and costs. A modification of nominal group process was used to generate a preliminary list of activities. A first round of field testing was conducted with 83 primary care physicians, and a second round of field testing with an additional 172 physicians.The first round of field testing resulted in 1 activity being deleted from the family medicine list. Support for the remaining activities was strong. The second round of field testing showed strong support for all activities. The family medicine and internal medicine groups independently selected 3 activities that were the same, so the final lists reflect 12 unique activities that could improve clinical care.Physician panels in the primary care specialties of family medicine, internal medicine, and pediatrics identified common clinical activities that could lead to higher quality care and better use of finite clinical resources. Field testing showed support among physicians for the evidence supporting the activities, the potential positive impact on medical care quality and cost, and the ease with which the activities could be performed. We recommend that these "Top 5" lists of activities be implemented in primary care practice across the United States.
View details for DOI 10.1001/archinternmed.2011.231
View details for Web of Science ID 000293642800016