- General Inpatient Medicine, Quality Improvement
- Clinical Trials
- Development of a Perioperative Medical Service for surgical co-management
- Inpatient Medical Education of Housestaff
- Internal Medicine
- Promoting physician resilience as a tool for wellness
Clinical Professor, Medicine
Associate Residency Program Director, Internal Medicine Residency Program (2009 - 2019)
Division Chief, Hospital Medicine, Stanford University School of Medicine (2017 - Present)
Director, Hospitalist Program, Stanford (2011 - 2017)
Medical Director, General Medicine Inpatient Wards (2012 - Present)
Honors & Awards
Gold-Headed Cane Award for "compassion, dedication to medicine, and a desire to serve", Awarded to one graduating medical student, UT Houston medical school (1997)
Excellence in Clinical Teaching "Golden Rattle Award", Pediatrics Dept. UTMB (Texas) (2004)
Clinical Women in Medicine Award, American Medical Womens Association (AMWA) National Award (2006)
AOA Lifetime Member, Alpha Omega Alpha Lifetime Member Induction (2006)
Inducted as Faculty Mentor for Osler Student Society, UTMB (Texas) McGovern Academy of Oslerian Medicine (2006)
National Educator's Award, "Who's Who amongst Teachers and Educators" across the nation (2007)
President's Professionalism Project Award, University of Texas Medical Branch (2007)
Divisional Teaching Award, General Medical Disciplines, Stanford University Medical Center (2010)
Arthur L. Bloomfield Award for Excellence in Clinical Teaching, Stanford University Medical School (2011)
Distinguished Teacher and Mentor Award, American College of Physicians (2012)
Malinda S. Mitchell Award for Quality & Service, Stanford Hospital and Clinics (2013)
Boards, Advisory Committees, Professional Organizations
Member, Association of Program Directors in Internal Medicine (2003 - Present)
Member, Society of Hospital Medicine (2015 - Present)
Fellow, American College of Physicians (2009 - Present)
General Internist, Society of General Internal Medicine (2012 - Present)
Residency: University of Texas Health Sciences Center Internal Medicine Residency (2001) TX
Internship: University of Texas Health Sciences Center Internal Medicine Residency (1998) TX
Board Certification: American Board of Internal Medicine, Internal Medicine (2002)
Internal Medicine & Pediatrics, Univ. of Texas-Houston, Med/Peds Residency (2001)
M.D., Univ. of Texas- Houston, Medical Degree (1997)
B.A. (Honors), U.C. Berkeley, Major- Biology Minor- Creative Writing (1993)
Current Research and Scholarly Interests
Medical education research; Intergenerational teaching/learning; Analysis of effects of duty hour regulations on housestaff training and ways to improve the system
Graduate and Fellowship Programs
Merits of Surgical Comanagement of Patients With Hip Fracture by Dedicated Orthopaedic Hospitalists.
Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews
2021; 5 (3)
Rotating medical consultants, hospitalists or geriatricians, are involved in the care of patients with hip fracture, often after medical complications have already occurred. In August 2012, we implemented a unique surgical comanagement (SCM) model in which the same Internal Medicine hospitalists are dedicated year-round to the orthopaedic surgery service. We examine whether this SCM model was associated with a decrease in medical complications, length of stay, and inpatient mortality in patients with hip fracture admitted at our institution, compared with the previous model.We included 2,252 admissions to the orthopaedic surgery service with a hip fracture between 2009 and 2018 (757 pre-SCM and 1495 post-SCM). We adjusted for age, Charlson comorbidity score, and operating time in all regression analyses.Mean Charlson comorbidity score (1.6 versus 1.2) and median case mix index (2.1 versus 1.9) were higher in the post-SCM group. A 32% decrease was observed in the odds of having ≥1 medical complication(s) (odds ratio, 0.68 [95% confidence interval, 0.50 to 0.91], P = 0.009) post-SCM. No change was observed in length of stay or inpatient mortality despite an increase in medical complexity post-SCM.Having dedicated orthopaedic hospitalists may contribute to fewer medical complications in patients with hip fracture.
View details for DOI 10.5435/JAAOSGlobal-D-20-00231
View details for PubMedID 33720101
Factors Associated with Hospital-Acquired Delirium in Patients 18–65 Years Old
J GEN INTERN MED
View details for DOI 10.1007/s11606-020-06378-w
Characteristics of Younger and Older Adults with Hospital-Acquired Delirium: a Claims Data Study Spanning 14 years
J GEN INTERN MED
View details for DOI 10.1007/s11606-020-06379-9
COVID-19 coagulopathy and thrombosis: Analysis of hospital protocols in response to the rapidly evolving pandemic
2020; 196: 355–58
As the Coronavirus disease 2019 (COVID-19) pandemic spread to the US, so too did descriptions of an associated coagulopathy and thrombotic complications. Hospitals created institutional protocols for inpatient management of COVID-19 coagulopathy and thrombosis in response to this developing data. We collected and analyzed protocols from 21 US academic medical centers developed between January and May 2020. We found greatest consensus on recommendations for heparin-based pharmacologic venous thromboembolism (VTE) prophylaxis in COVID-19 patients without contraindications. Protocols differed regarding incorporation of D-dimer tests, dosing of VTE prophylaxis, indications for post-discharge pharmacologic VTE prophylaxis, how to evaluate for VTE, and the use of empiric therapeutic anticoagulation. These findings support ongoing efforts to establish international, evidence-based guidelines.
View details for DOI 10.1016/j.thromres.2020.09.018
View details for Web of Science ID 000592174300032
View details for PubMedID 32977136
View details for PubMedCentralID PMC7492800
Portable Ultrasound Device Usage and Learning Outcomes Among Internal Medicine Trainees: A Parallel-Group Randomized Trial.
Journal of hospital medicine
2020; 15 (2): e1–e6
BACKGROUND: Little is known about how to effectively train residents with point-of-care ultrasonography (POCUS) despite increasing usage.OBJECTIVE: This study aimed to assess whether handheld ultrasound devices (HUDs), alongside a year-long lecture series, improved trainee image interpretation skills with POCUS.METHODS: Internal medicine intern physicians (N = 149) at a single academic institution from 2016 to 2018 participated in the study. The 2017 interns (n = 47) were randomized 1:1 to receive personal HUDs (n = 24) for patient care vs no-HUDs (n = 23). All 2017 interns received a repeated lecture series regarding cardiac, thoracic, and abdominal POCUS. Interns were assessed on their ability to interpret POCUS images of normal/abnormal findings. The primary outcome was the difference in end-of-the-year assessment scores between interns randomized to receive HUDs vs not. Secondary outcomes included trainee scores after repeating lectures and confidence with POCUS. Intern scores were also compared with historical (2016, N = 50) and contemporaneous (2018, N = 52) controls who received no lectures.RESULTS: Interns randomized to HUDs did not have significantly higher image interpretation scores (median HUD score: 0.84 vs no-HUD score: 0.84; P = .86). However, HUD interns felt more confident in their abilities. The 2017 cohort had higher scores (median 0.84), compared with the 2016 historical control (median 0.71; P = .001) and 2018 contemporaneous control (median 0.48; P < .001). Assessment scores improved after first-time exposure to the lecture series, while repeated lectures did not improve scores.CONCLUSIONS: Despite feeling more confident, personalized HUDs did not improve interns' POCUS-related knowledge or interpretive ability. Repeated lecture exposure without further opportunities for deliberate practice may not be beneficial for mastering POCUS.
View details for DOI 10.12788/jhm.3351
View details for PubMedID 32118565
Baricitinib plus Remdesivir for Hospitalized Adults with Covid-19.
The New England journal of medicine
Severe coronavirus disease 2019 (Covid-19) is associated with dysregulated inflammation. The effects of combination treatment with baricitinib, a Janus kinase inhibitor, plus remdesivir are not known.We conducted a double-blind, randomized, placebo-controlled trial evaluating baricitinib plus remdesivir in hospitalized adults with Covid-19. All the patients received remdesivir (≤10 days) and either baricitinib (≤14 days) or placebo (control). The primary outcome was the time to recovery. The key secondary outcome was clinical status at day 15.A total of 1033 patients underwent randomization (with 515 assigned to combination treatment and 518 to control). Patients receiving baricitinib had a median time to recovery of 7 days (95% confidence interval [CI], 6 to 8), as compared with 8 days (95% CI, 7 to 9) with control (rate ratio for recovery, 1.16; 95% CI, 1.01 to 1.32; P = 0.03), and a 30% higher odds of improvement in clinical status at day 15 (odds ratio, 1.3; 95% CI, 1.0 to 1.6). Patients receiving high-flow oxygen or noninvasive ventilation at enrollment had a time to recovery of 10 days with combination treatment and 18 days with control (rate ratio for recovery, 1.51; 95% CI, 1.10 to 2.08). The 28-day mortality was 5.1% in the combination group and 7.8% in the control group (hazard ratio for death, 0.65; 95% CI, 0.39 to 1.09). Serious adverse events were less frequent in the combination group than in the control group (16.0% vs. 21.0%; difference, -5.0 percentage points; 95% CI, -9.8 to -0.3; P = 0.03), as were new infections (5.9% vs. 11.2%; difference, -5.3 percentage points; 95% CI, -8.7 to -1.9; P = 0.003).Baricitinib plus remdesivir was superior to remdesivir alone in reducing recovery time and accelerating improvement in clinical status among patients with Covid-19, notably among those receiving high-flow oxygen or noninvasive ventilation. The combination was associated with fewer serious adverse events. (Funded by the National Institute of Allergy and Infectious Diseases; ClinicalTrials.gov number, NCT04401579.).
View details for DOI 10.1056/NEJMoa2031994
View details for PubMedID 33306283
The genealogy of teaching clinical reasoning and diagnostic skill: the GEL Study.
Diagnosis (Berlin, Germany)
The genealogy of graduate medical education in America begins at the bedside. However, today's graduate medical trainees work in a training environment that is vastly different from medical training a century ago. The goal of the Graduate Medical Education Laboratory (GEL) Study, supported by the American Medical Association's (AMA) "Reimagining Residency" initiative, is to determine the factors in the training environment that most contribute to resident well-being and developing diagnostic skills. We believe that increasing time at the bedside will improve clinical skill, increase professional fulfillment, and reduce workplace burnout. Our graduate medical education laboratory will test these ideas to understand which interventions can be shared among all training programs. Through the GEL Study, we aim to ensure resident readiness for practice as we understand, then optimize, the learning environment for trainees and staff.
View details for DOI 10.1515/dx-2019-0107
View details for PubMedID 32146439
Osteoarthritis risk is reduced after treatment with ticagrelor compared to clopidogrel: a propensity score matching analysis.
Arthritis & rheumatology (Hoboken, N.J.)
Osteoarthritis (OA) is a common cause of joint pain and disability, and effective treatments are lacking. Extracellular adenosine has anti-inflammatory effects and can prevent and treat OA in animal models. Ticagrelor and clopidogrel are both used in patients with coronary artery disease, but only ticagrelor increases extracellular adenosine. The aim of this study was to determine whether treatment with ticagrelor was associated with a lower risk of OA.We conducted a 1:2 propensity score matching analysis using the Optum Clinformatics™ Data Mart from 2011 to 2017. We included patients who received either ticagrelor or clopidogrel for at least 90 days and excluded those with a prior diagnosis of OA or inflammatory arthritis. OA was identified using International Classification of Diseases codes. The primary outcome was the time to diagnosis of OA after treatment with ticagrelor versus clopidogrel.Our propensity score matched cohort consisted of 7,007 ticagrelor-treated patients and 14,014 clopidogrel-treated patients, with a median number of days on treatment of 287 and 284 respectively. For both groups, the mean age was 64 years, and 73% of the patients were male. Multivariate Cox-regression analysis estimated a hazard ratio of 0.71 (95% CI 0.64-0.79, p<0.001) for developing OA after treatment with ticagrelor compared to clopidogrel.Treatment with ticagrelor was associated with a 29% lower risk of developing OA compared to clopidogrel over five years of follow-up. We hypothesize that the reduction in OA seen in patients who received ticagrelor may in part be due to increased extracellular adenosine.
View details for DOI 10.1002/art.41412
View details for PubMedID 32564514
Surgical Comanagement by Hospitalists: Continued Improvement Over 5 Years
Journal of Hospital Medicine
View details for DOI 10.12788/jhm.3363
- Co-Management by Hospitalists: Why it makes clinical and fiscal sense. The American journal of medicine 2019
- Reducing Telemetry Use Is Safe: A Retrospective Analysis of Rapid Response Team and Code Events After a Successful Intervention to Reduce Telemetry Use AMERICAN JOURNAL OF MEDICAL QUALITY 2019; 34 (4): 398–401
Initiative for prevention and early identification of delirium in medical-surgical units: Lessons learnt in the past five years.
The American journal of medicine
BACKGROUND: Delirium is an acute change in mental status affecting 10-64% of hospitalized patients, and may be preventable in 30-40% cases. In October 2013, a task force for delirium prevention and early identification in medical-surgical units was formed at our hospital. We studied if our standardized protocol prevented delirium among high-risk patients.METHODS: We studied 105,455 patient encounters between November 2013 and January 2018. Since November 2013, there has been ongoing education to decrease deliriogenic medications use. Since 2014, nurses screen all patients for presence or absence of delirium using confusion assessment method (CAM). Since 2015, nurses additionally screen all patients for risk of delirium. In 2015, a physician order set for delirium was created. Non-pharmacological measures are implemented for high-risk or CAM positive patients.RESULTS: 98.8% of patient encounters had CAM screening, and 99.6% had delirium risk screening. Since 2013, odds of opiate use decreased by 5.0% per year (P<0.001), and odds of benzodiazepines use decreased by 8.0% per year (P<0.001). There was no change in anticholinergics use. In the adjusted analysis, since 2015, odds of delirium decreased by 25.3% per year among high-risk patients (N=21,465; P<0.001). Among high-risk patients or those diagnosed with delirium (N=22,121), estimated LOS decreased by 0.13days per year (P<0.001), odds of inpatient mortality decreased by 16.0% per year (P=0.011), and odds of discharge to nursing home decreased by 17.1% per year (P<0.001).CONCLUSION: With high clinician engagement and simplified workflows, our delirium initiative has shown sustained results.
View details for DOI 10.1016/j.amjmed.2019.05.035
View details for PubMedID 31228413
- State of Research in Adult Hospital Medicine: Results of a National Survey JOURNAL OF HOSPITAL MEDICINE 2019; 14 (4): 207–11
- ACUTE KIDNEY INJURY IN LOWER-EXTREMITY JOINT ARTHROPLASTY Clinical Epidemiology, Prevention, and Management JBJS REVIEWS 2019; 7 (4)
State of Research in Adult Hospital Medicine: Results of a National Survey.
Journal of hospital medicine
2019; 14 (4): 207–11
BACKGROUND: Little is known about the state of research in academic hospital medicine (HM) despite the substantial growth of this specialty.METHODS: We used the Society of Hospital Medicine (SHM) membership database to identify research programs and their leadership. In addition, the members of the SHM Research Committee identified individuals who lead research programs in HM. A convenience sample of programs and individuals was thus created. A survey instrument containing questions regarding institutional information, research activities, training opportunities, and funding sources was pilot tested and refined for electronic dissemination. Data were summarized using descriptive statistics.RESULTS: A total of 100 eligible programs and corresponding individuals were identified. Among these programs, 28 completed the survey in its entirety (response rate 28%). Among the 1,586 faculty members represented in the 28 programs, 192 (12%) were identified as engaging in or having obtained extramural funding for research, and 656 (41%) were identified as engaging in quality improvement efforts. Most programs (61%) indicated that they received $500,000 or less in research funding, whereas 29% indicated that they received >$1 million in funding. Major sources of grant support included the Agency for Healthcare Research and Quality, National Institutes of Health, and the Veterans Health Administration. Only five programs indicated that they currently have a research fellowship program in HM. These programs cited lack of funding as a major barrier to establishing fellowships. Almost half of respondents (48%) indicated that their faculty published between 11-50 peer-reviewed manuscripts each year.CONCLUSION: This survey provides the first national summary of research activities in HM. Future waves of the survey can help determine whether the research footprint of the field is growing.
View details for PubMedID 30933670
Acute Kidney Injury in Lower-Extremity Joint Arthroplasty: Clinical Epidemiology, Prevention, and Management.
2019; 7 (4): e9
View details for PubMedID 31045689
- Comparison of Outcomes for Adult Inpatients With Sickle Cell Disease Cared for by Hospitalists Versus Hematologists. American journal of medical quality : the official journal of the American College of Medical Quality 2019: 1062860619892060
Thrombophilia testing in the inpatient setting: impact of an educational intervention.
BMC medical informatics and decision making
2019; 19 (1): 167
Thrombophilia testing is frequently ordered in the inpatient setting despite its limited impact on clinical decision-making and unreliable results in the setting of acute thrombosis or ongoing anticoagulation. We sought to determine the effect of an educational intervention in reducing inappropriate thrombophilia testing for hospitalized patients.During the 2014 academic year, we implemented an educational intervention with a phase implementation design for Internal Medicine interns at Stanford University Hospital. The educational session covering epidemiology, appropriate thrombophilia evaluation and clinical rationale behind these recommendations. Their ordering behavior was compared with a contemporaneous control (non-medicine and private services) and a historical control (interns from prior academic year). From the analyzed data, we determined the proportion of inappropriate thrombophilia testing of each group. Logistic generalized estimating equations were used to estimate odds ratios for inappropriate thrombophilia testing associated with the intervention.Of 2151 orders included, 934 were deemed inappropriate (43.4%). The two intervention groups placed 147 orders. A pooled analysis of ordering practices by intervention groups revealed a trend toward reduction of inappropriate ordering (p = 0.053). By the end of the study, the intervention groups had significantly lower rates of inappropriate testing compared to historical or contemporaneous controls.A brief educational intervention was associated with a trend toward reduction in inappropriate thrombophilia testing. These findings suggest that focused education on thrombophilia testing can positively impact inpatient ordering practices.
View details for DOI 10.1186/s12911-019-0889-6
View details for PubMedID 31429747
Genomics in medicine: a novel elective rotation for internal medicine residents.
Postgraduate medical journal
It is well recognised that medical training globally and at all levels lacks sufficient incorporation of genetics and genomics education to keep up with the rapid advances and growing application of genomics to clinical care. However, the best strategy to implement these desired changes into postgraduate medical training and engage learners is still unclear. We developed a novel elective rotation in 'Genomic Medicine and Undiagnosed Diseases' for categorical Internal Medicine Residents to address this educational gap and serve as an adaptable model for training that can be applied broadly across different specialties and at other institutions. Key curriculum goals achieved include increased understanding about genetic testing modalities and tools available for diagnosis and risk analysis, the role of genetics-trained allied health professionals, and indications and limitations of genetic and genomic testing in both rare and common conditions.
View details for DOI 10.1136/postgradmedj-2018-136355
View details for PubMedID 31439813
Determinants of Cost Variation in Total Hip and Knee Arthroplasty: Implications for Alternative Payment Models.
The Journal of the American Academy of Orthopaedic Surgeons
Alternative payment models have been proposed to deliver high-quality, cost-effective care. Under these models, payments may be shared between the hospital and the post-acute care services. Post-acute care services may account for one-third of the episode costs for total hip or knee arthroplasty (THA/TKA). Because hospitals or episode initiators bear notable financial risks in these payment models with minimal risk adjustment for complexity, it has been suggested these models may lead to prospective selection of healthier and younger patients. Studies evaluating the effect of patient demographics, medical complexity, and surgical characteristics on the cost of index hospitalization have been limited. We aimed to (1) quantify the impact of patient demographics, medical complexity, and surgical characteristics (type of anesthesia and operating time) on variation in direct cost of index hospitalization and (2) examine the association of these characteristics with discharge with home health services or to rehabilitation facility.Retrospective study of 3,542 patients admitted to our hospital for elective THA/TKA between 2012 and 2017. Multivariable generalized estimating equations were used for analysis.Patient demographics and medical complexity accounted for 6.2% (THA) and 5.6% (TKA) of variation in direct cost of index hospitalization. Surgical characteristics accounted for 37.1% (THA) and 35.3% (TKA) of the cost variation. One thousand one hundred eighty-three (53.4%) patients were discharged with home health services, and 1,237 (29.4%) were discharged to rehabilitation facility. Patient demographics and higher medical complexity were markedly associated with discharge with home health services or to rehabilitation facility after THA/TKA.Patient demographics and medical complexity had minimal impact on variation in direct cost of index hospitalization for elective THA/TKA compared with surgical characteristics but were markedly associated with discharge with home health services or to rehabilitation facility. Having additional risk adjustment in these payment models could mitigate concerns about access to care for higher risk, higher cost patients.
View details for DOI 10.5435/JAAOS-D-18-00718
View details for PubMedID 31192883
- Assessing the Relationship Between American Heart Association Atherosclerotic Cardiovascular Disease Risk Score and Coronary Artery Imaging Findings JOURNAL OF COMPUTER ASSISTED TOMOGRAPHY 2018; 42 (6): 898–905
Reducing Telemetry Use Is Safe: A Retrospective Analysis of Rapid Response Team and Code Events After a Successful Intervention to Reduce Telemetry Use.
American journal of medical quality : the official journal of the American College of Medical Quality
Interventions guiding appropriate telemetry utilization have successfully reduced use at many hospitals, but few studies have examined their possible adverse outcomes. The authors conducted a successful intervention to reduce telemetry use in 2013 on a hospitalist service using educational modules, routine review, and financial incentives. The association of reduced telemetry use with the incidence of rapid response team (RRT) and code activations was assessed in a retrospective cohort study of 210 patients who experienced a total of 233 RRT and code events on the inpatient internal medicine services from January 2012 through March 2015 at a tertiary care center. The incidence of adverse events for the hospitalist service was not significantly different during the intervention and postintervention period as compared to the preintervention period. Reducing inappropriate telemetry use was not associated with an increase in the incidence rates of RRT and code events.
View details for PubMedID 30293436
- Surgical Comanagement by Hospitalists in Colorectal Surgery ELSEVIER SCIENCE INC. 2018: 404-+
Surgical Comanagement by Hospitalists in Colorectal Surgery.
Journal of the American College of Surgeons
BACKGROUND: Patients with increasing age and medical complexity are undergoing colorectal surgery. Medical complications are not uncommon, and may contribute to higher mortality. We implemented a surgical co-management (SCM) model in July 2014 at our institution where same two SCM hospitalists were dedicated to Colorectal surgery year round. Each patient was screened daily by a SCM hospitalist for prevention and management of medical complications. Prior to SCM, hospitalists were typically consulted after medical complications had occurred.STUDY DESIGN: Pre-post study at an academic medical center with 938 patients in the pre-SCM group (July 2012 to June 2014), and 1,062 patients in the post-SCM group (July 2014 to May 2016). We evaluated if SCM by hospitalists improved outcomes of patients in Colorectal surgery.RESULTS: There was no significant difference in medical complications, patient satisfaction, or 30-day readmission rate to our institution for medical cause with the SCM intervention. This intervention was associated with a significant decrease in the proportion of patients transferred to intensive care unit after rapid response team calls (RR, 0.25 [95% CI, 0.05 to 0.84], P = 0.039), proportion of patients with LOS ≥5 days (RR, 0.73 [95% CI, 0.64 to 0.83], P <0.001), use of medical consultants (RR, 0.75 [95% CI, 0.63 to 0.89], P = 0.001), and the median direct cost of care by 10.3% (P = 0.0002).CONCLUSIONS: SCM intervention was associated with a decrease in transfers to intensive care unit after rapid response team call, LOS, medical consultants, and the cost of care.
View details for PubMedID 30030136
- Lean-Based Redesign of Multidisciplinary Rounds on General Medicine Service JOURNAL OF HOSPITAL MEDICINE 2018; 13 (7): 482–85
Diabetes and Hyperglycemia in Lower-Extremity Total Joint Arthroplasty: Clinical Epidemiology, Outcomes, and Management.
2018; 6 (5): e10
View details for PubMedID 29847443
- DIABETES AND HYPERGLYCEMIA IN LOWER-EXTREMITY TOTAL JOINT ARTHROPLASTY Clinical Epidemiology, Outcomes, and Management JBJS REVIEWS 2018; 6 (5)
Lean-Based Redesign of Multidisciplinary Rounds on General Medicine Service.
Journal of hospital medicine
Multidisciplinary rounds (MDR) facilitate timely communication amongst the care team and with patients. We used Lean techniques to redesign MDR on the teaching general medicine service.To examine if our Lean-based new model of MDR was associated with change in the primary outcome of length of stay (LOS) and secondary outcomes of discharges before noon, documentation of estimated discharge date (EDD), and patient satisfaction.This is a pre-post study. The preperiod (in which the old model of MDR was followed) comprised 4000 patients discharged between September 1, 2013, and October 22, 2014. The postperiod (in which the new model of MDR was followed) comprised 2085 patients between October 23, 2014, and April 30, 2015.Lean-based redesign of MDR.LOS, discharges before noon, EDD, and patient satisfaction.There was no change in the mean LOS. Discharges before noon increased from 6.9% to 10.7% (P < .001). Recording of EDD increased from 31.4% to 41.3% (P < .001). There was no change in patient satisfaction.Lean-based redesign of MDR was associated with an increase in discharges before noon and in recording of EDD.
View details for PubMedID 29394300
Assessing the Relationship Between American Heart Association Atherosclerotic Cardiovascular Disease Risk Score and Coronary Artery Imaging Findings.
Journal of computer assisted tomography
The aim of this study was to characterize the relationship between computed tomography angiography imaging characteristics of coronary artery and atherosclerotic cardiovascular disease (ASCVD) score.We retrospectively identified all patients who underwent a coronary computed tomography angiography at our institution from December 2013 to July 2016, then we calculated the 10-year ASCVD score. We characterized the relationship between coronary artery imaging findings and ASCVD risk score.One hundred fifty-one patients met our inclusion criteria. Patients with a 10-year ASCVD score of 7.5% or greater had significantly more arterial segments showing stenosis (46.4%, P = 0.008) and significantly higher maximal plaque thickness (1.25 vs 0.53, P = 0.001). However, among 56 patients with a 10-year ASCVD score of 7.5% or greater, 30 (53.6%) had no arterial stenosis. Furthermore, among the patients with a 10-year ASCVD score of less than 7.5%, 24 (25.3%) had some arterial stenosis.There is some concordance but not a perfect overlap between 10-year ASCVD risk scores and coronary artery imaging findings.
View details for PubMedID 30407249
Factors Associated With Delayed Discharge on General Medicine Service at an Academic Medical Center.
Journal for healthcare quality : official publication of the National Association for Healthcare Quality
Lack of collaboration between care teams and patients/families has been associated with delayed discharge from the hospital. In this study, we determine whether patients' awareness of the estimated date of discharge (EDD) was associated with a decrease in delayed discharge, and determine the factors associated with a delayed discharge. A total of 221 patients admitted to the General Medicine service between July and September 2014 were included in the study. Estimated date of discharge was identified within 36 hours of admission. The bedside nurse communicated this EDD to the patient/family. Patients were interviewed to identify whether they were aware of their EDD. Bedside nurses were interviewed to identify barriers to discharge. In our study, 49.8% of the patients had a delayed discharge. Patients who were aware of their EDD were less likely to have a delayed discharge (odds ratio [OR], 0.3 [95% confidence interval (CI), 0.1-0.6], p < .001). Patients who were discharged on Saturday or Sunday (OR, 4.8 [95% CI, 1.7-14.6], p < .001) and patients who were waiting for physicians' consult (OR, 4.5 [95% CI, 1.6-14.4], p = .007) were more likely to have a delayed discharge. Early identification of the EDD and communicating it with the care team and the patient/family, mobilizing resources for safe weekend discharges, and creating efficient process for consultations might decrease delayed discharges.
View details for DOI 10.1097/JHQ.0000000000000126
View details for PubMedID 29315151
- A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback POSTGRADUATE MEDICAL JOURNAL 2017; 93 (1106): 725–29
- Ketamine-Induced Mania During Treatment for Complex Regional Pain Syndrome. Pain medicine (Malden, Mass.) 2017
- Ketamine-Induced Mania During Treatment for Complex Regional Pain Syndrome. Pain medicine (Malden, Mass.) 2017
TRIAD VIII: Nationwide Multicenter Evaluation to Determine Whether Patient Video Testimonials Can Safely Help Ensure Appropriate Critical Versus End-of-Life Care.
Journal of patient safety
End-of-life interventions should be predicated on consensus understanding of patient wishes. Written documents are not always understood; adding a video testimonial/message (VM) might improve clarity. Goals of this study were to (1) determine baseline rates of consensus in assigning code status and resuscitation decisions in critically ill scenarios and (2) determine whether adding a VM increases consensus.We randomly assigned 2 web-based survey links to 1366 faculty and resident physicians at institutions with graduate medical education programs in emergency medicine, family practice, and internal medicine. Each survey asked for code status interpretation of stand-alone Physician Orders for Life-Sustaining Treatment (POLST) and living will (LW) documents in 9 scenarios. Respondents assigned code status and resuscitation decisions to each scenario. For 1 of 2 surveys, a VM was included to help clarify patient wishes.Response rate was 54%, and most were male emergency physicians who lacked formal advanced planning document interpretation training. Consensus was not achievable for stand-alone POLST or LW documents (68%-78% noted "DNR"). Two of 9 scenarios attained consensus for code status (97%-98% responses) and treatment decisions (96%-99%). Adding a VM significantly changed code status responses by 9% to 62% (P ≤ 0.026) in 7 of 9 scenarios with 4 achieving consensus. Resuscitation responses changed by 7% to 57% (P ≤ 0.005) with 4 of 9 achieving consensus with VMs.For most scenarios, consensus was not attained for code status and resuscitation decisions with stand-alone LW and POLST documents. Adding VMs produced significant impacts toward achieving interpretive consensus.
View details for DOI 10.1097/PTS.0000000000000357
View details for PubMedID 28198722
A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback.
Postgraduate medical journal
Most residency programmes do not have a formal high value care curriculum. Our goal was to design and implement a multidisciplinary high value care curriculum specifically targeted at interns.Our curriculum was designed with multidisciplinary input from attendings, fellows and residents at Stanford. Curricular topics were inspired by the American Board of Internal Medicine's Choosing Wisely campaign, Alliance for Academic Internal Medicine, American College of Physicians and Society of Hospital Medicine. Our topics were as follows: introduction to value-based care; telemetry utilisation; lab ordering; optimal approach to thrombophilia work-ups and fresh frozen plasma use; optimal approach to palliative care referrals; antibiotic stewardship; and optimal approach to imaging for low back pain. Our curriculum was implemented at the Stanford Internal Medicine residency programme over the course of two academic years (2014 and 2015), during which 100 interns participated in our high value care curriculum. After each high value care session, interns were offered the opportunity to complete surveys regarding feedback on the curriculum, self-reported improvements in knowledge, skills and attitudinal module objectives, and quiz-based knowledge assessments.The overall survey response rate was 67.1%. Overall, the material was rated as highly useful on a 5-point Likert scale (mean 4.4, SD 0.6). On average, interns reported a significant improvement in their self-rated knowledge, skills and attitudes after the six seminars (mean improvement 1.6 points, SD 0.4 (95% CI 1.5 to 1.7), p<0.001).We successfully implemented a novel high value care curriculum that specifically targets intern physicians.
View details for PubMedID 28663352
- Integrating Mobile Fitness Trackers Into the Practice of Medicine AMERICAN JOURNAL OF LIFESTYLE MEDICINE 2017; 11 (1): 77–79
Integrating Mobile Fitness Trackers Into the Practice of Medicine.
American journal of lifestyle medicine
2017; 11 (1): 77–79
Mobile fitness trackers are increasingly used by patients as a means to become more involved in their own self-care; however, these devices measure disparate outcomes that may have equivocal relevance to true health status. It is vital for physicians to interpret both the quality and accuracy of the information that these trackers provide, and it is important to delineate which role, if any, these devices may serve in promoting quality patient care in the future. Potential benefits of mobile fitness trackers include the ability to motivate patients toward a healthier lifestyle, to develop a community of like-minded individuals seeking to improve their health, as well as to create an environment of sustainability and accountability for long-term promotion of health maintenance. However, limitations include the fact that mobile fitness trackers are not regulated by the Food and Drug Administration, that the employed metrics are not necessarily the best surrogates for true health status, and that the accuracy of measured endpoints has not yet been proven. As mobile fitness trackers both continue to rise in popularity and become increasingly sophisticated, physicians must be equipped to interpret and use this technology to better serve patients within an ever-changing, more technology-reliant health care system.
View details for PubMedID 30202316
Prevalence and Financial Impact of Inappropriate Thrombophilia Testing in the Inpatient Hospital Setting: A Retrospective Analysis
AMER SOC HEMATOLOGY. 2016
View details for Web of Science ID 000394452508066
A Multidisciplinary Initiative to Increase Inpatient Discharges Before Noon
JOURNAL OF NURSING ADMINISTRATION
2016; 46 (12): 630-635
The aim of this study is to evaluate the effect of 2 hospital-wide interventions on achieving a discharge-before-noon rate of 40%.A multidisciplinary team led by administrative and physician leadership developed a plan to diminish capacity constraints by minimizing late afternoon hospital discharges using 2 patient flow management techniques.The study was a preintervention/postintervention retrospective analysis observing all inpatients discharged across 19 inpatient units in a 484-bed, academic teaching hospital measuring calendar month discharge-before-noon percentage, patient satisfaction, and readmission rates. Patient satisfaction and readmission rates were used as baseline metrics.The discharge-before-noon percentage increased from 14% in the 11-month preintervention period to an average of 24% over the 11-month postintervention period, whereas patient satisfaction scores and readmission rates remained stable.Implementation of the 2 interventions successfully increased the percentage of discharges before noon yet did not achieve the goal of 40%. Patient satisfaction and readmission rates were not negatively impacted by the program.
View details for DOI 10.1097/NNA.0000000000000418
View details for PubMedID 27851703
- R-SCAN: Imaging for Low Back Pain. Journal of the American College of Radiology 2016; 13 (11): 1385-1386 e1
- The State of Medical Student Performance Evaluations: Improved Transparency or Continued Obfuscation? ACADEMIC MEDICINE 2016; 91 (11): 1534–39
The State of Medical Student Performance Evaluations: Improved Transparency or Continued Obfuscation?
2016; 91 (11): 1534-1539
The medical student performance evaluation (MSPE), a letter summarizing academic performance, is included in each medical student's residency application. The extent to which medical schools follow Association of American Medical Colleges (AAMC) recommendations for comparative and transparent data is not known. This study's purpose was to describe the content, interpretability, and transparency of MSPEs.This cross-sectional study examined one randomly selected MSPE from every Liaison Committee on Medical Education-accredited U.S. medical school from which at least one student applied to the Stanford University internal medical residency program during the 2013-2014 application cycle. The authors described the number, distribution, and range of key words and clerkship grades used in the MSPEs and the proportions of schools with missing or incomplete data.The sample included MSPEs from 117 (89%) of 131 medical schools. Sixty schools (51%) provided complete information about clerkship grade and key word distributions. Ninety-six (82%) provided comparative data for clerkship grades, and 71 (61%) provided complete key word data. Key words describing overall performance were extremely heterogeneous, with a total of 72 used and great variation in the assignment of the top designation (median: 24% of students; range: 1%-60%). There was also great variation in the proportion of students awarded the top internal medicine clerkship grade (median: 29%; range: 2%-90%).The MSPE is a critical component of residency applications, yet data contained within MSPEs are incomplete and variable. Approximately half of U.S. medical schools do not follow AAMC guidelines for MSPEs.
View details for PubMedID 26703411
- R-SCAN: Imaging for Uncomplicated Acute Rhinosinusitis. Journal of the American College of Radiology 2016
A resident-created hospitalist curriculum for internal medicine housestaff.
Journal of hospital medicine
2016; 11 (9): 646-649
The growth of hospital medicine has led to new challenges, and recent graduates may feel unprepared to meet the expanding clinical duties expected of hospitalists. At our institution, we created a resident-inspired hospitalist curriculum to address the training needs for the next generation of hospitalists. Our program provided 3 tiers of training: (1) clinical excellence through improved training in underemphasized areas of hospital medicine, (2) academic development through required research, quality improvement, and medical student teaching, and (3) career mentorship. In this article, we describe the genesis of our program, our final product, and the challenges of creating a curriculum while being internal medicine residents. Journal of Hospital Medicine 2016. © 2016 Society of Hospital Medicine.
View details for DOI 10.1002/jhm.2590
View details for PubMedID 27079160
Surgical Comanagement by Hospitalists Improves Patient Outcomes: A Propensity Score Analysis.
Annals of surgery
2016; 264 (2): 275-282
The aim of the study was to examine the impact of a surgical comanagement (SCM) hospitalist program on patient outcomes at an academic institution.Prior studies may have underestimated the impact of SCM due to methodological shortcomings.This is a retrospective study utilizing a propensity score-weighted intervention (n = 16,930) and control group (n = 3695). Patients were admitted between January 2009 to July 2012 (pre-SCM) and September 2012 to September 2013 (post-SCM) to Orthopedic or Neurosurgery at our institution. Using propensity score methods, linear regression, and a difference-in-difference approach, we estimated changes in outcomes between pre and post periods, while adjusting for confounding patient characteristics.The SCM intervention was associated with a significant differential decrease in the proportion of patients with at least 1 medical complication [odds ratio (OR) 0.86; 95% confidence interval (CI), 0.74-0.96; P = 0.008), the proportion of patients with length of stay at least 5 days (OR 0.75; 95% CI, 0.67-0.84; P < 0.001), 30-day readmission rate for medical cause (OR 0.67; 95% CI, 0.52-0.81; P < 0.001), and the proportion of patients with at least 2 medical consultants (OR 0.55; 95% CI, 0.49-0.63; P < 0.001). There was no significant change in patient satisfaction (OR 1.08; 95% CI, 0.87-1.33; P = 0.507). We estimated average savings of $2642 to $4303 per patient in the post-SCM group. The overall provider satisfaction with SCM was 88.3%.The SCM intervention reduces medical complications, length of stay, 30-day readmissions, number of consultants, and cost of care.
View details for DOI 10.1097/SLA.0000000000001629
View details for PubMedID 26764873
LOS OUTLIERS: A CHALLENGING PROBLEM FOR BOTH THE TEACHING AND PRIVATE NON-TEACHING GENERAL MEDICINE SERVICES AT STANFORD HOSPITAL
SPRINGER. 2016: S294
View details for Web of Science ID 000392201600372
- The Medical Education of Generation Y. Academic psychiatry 2016; 40 (2): 382-385
R-SCAN: Imaging for Headache.
Journal of the American College of Radiology : JACR
2016; 13 (12 Pt A): 1534–35.e1
View details for PubMedID 28341311
- Hospitalist intervention for appropriate use of telemetry reduces length of stay and cost JOURNAL OF HOSPITAL MEDICINE 2015; 10 (9): 627-632
- Eculizumab Induces Sustained Remission in a Patient With Refractory Primary Catastrophic Antiphospholipid Syndrome JCR-JOURNAL OF CLINICAL RHEUMATOLOGY 2015; 21 (6): 311-313
Diffuse Alveolar Damage in a Patient Receiving Dronedarone
2015; 147 (4): E131-E133
Dronedarone is an amiodarone-like antiarrhythmic with a modified structure. The addition of a methyl sulfonyl group theoretically reduces the toxicity of amiodarone, specifically, adverse thyroid and pulmonary effects. Although animal studies have implicated dronedarone as a cause of lung injury, to date controlled trials in humans have not demonstrated an association. A 68-year-old woman developed a dry cough and worsening respiratory distress after receiving dronedarone for 6 months. Discontinuation of dronedarone therapy and subsequent steroid therapy led to a dramatic improvement of symptoms. Dronedarone may be associated with interstitial lung disease. We believe that patients receiving dronedarone should have their diffusing capacity of lung for carbon monoxide and lung volumes monitored prior to initiation of therapy and frequently thereafter.
View details for DOI 10.1378/chest.14-1849
View details for Web of Science ID 000354606300001
View details for PubMedID 25846536
The Medical Education of Generation Y
View details for DOI 10.1007/s40596-015-0399-5
- Gastrointestinal Manifestations of Henoch-Schoenlein Purpura DIGESTIVE DISEASES AND SCIENCES 2013; 58 (1): 42-45
The Smartphone in Medicine: A Review of Current and Potential Use Among Physicians and Students
JOURNAL OF MEDICAL INTERNET RESEARCH
2012; 14 (5)
Advancements in technology have always had major impacts in medicine. The smartphone is one of the most ubiquitous and dynamic trends in communication, in which one's mobile phone can also be used for communicating via email, performing Internet searches, and using specific applications. The smartphone is one of the fastest growing sectors in the technology industry, and its impact in medicine has already been significant.To provide a comprehensive and up-to-date summary of the role of the smartphone in medicine by highlighting the ways in which it can enhance continuing medical education, patient care, and communication. We also examine the evidence base for this technology.We conducted a review of all published uses of the smartphone that could be applicable to the field of medicine and medical education with the exclusion of only surgical-related uses.In the 60 studies that were identified, we found many uses for the smartphone in medicine; however, we also found that very few high-quality studies exist to help us understand how best to use this technology.While the smartphone's role in medicine and education appears promising and exciting, more high-quality studies are needed to better understand the role it will have in this field. We recommend popular smartphone applications for physicians that are lacking in evidence and discuss future studies to support their use.
View details for DOI 10.2196/jmir.1994
View details for Web of Science ID 000309405400005
View details for PubMedID 23017375
View details for PubMedCentralID PMC3510747
- Interrelated Endocrinopathies: Hypothyroidism and Hyperprolactinemia Today’s Hosptialist 2007; April: 20-23
- Disseminated Candidiasis in IV Drug Abusers: A Distinctive Syndrome. Johns Hopkins Advanced Studies in Medicine 2006; 6: 82-85
- Advice to Medical Students Applying for Residency Alliance for Academic Internal Medicine 2005; 3 (4:10): 10
- Initial Approach to Gastrointestinal Bleeding Emergency Medicine 2005; 37 (10): 27-32
- Brain bloodflow abnormalities associated with oral cocaine use International Journal of Psychological Medicine 1997; 12 (2): 72-73