- General Inpatient Medicine, Quality Improvement
- Development of a Perioperative Medical Service for surgical co-management
- Inpatient Medical Education of Housestaff
- Internal Medicine
Clinical Professor, Medicine
Associate Residency Program Director, Internal Medicine Residency Program (2009 - Present)
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 Scienc Center Internal Medicine Residency (2001) TX
Internship:University of Texas Health Scienc Center Internal Medicine Residency (1998) TX
Board Certification: Internal Medicine, American Board of 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
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 DOI 10.12788/jhm.3136
View details for PubMedID 30933670
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 DOI 10.1177/1062860618805189
View details for PubMedID 30293436
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 DOI 10.1016/j.jamcollsurg.2018.06.011
View details for PubMedID 30030136
- Diabetes and Hyperglycemia in Lower-Extremity Total Joint Arthroplasty: Clinical Epidemiology, Outcomes, and Management. JBJS reviews 2018; 6 (5): e10
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 DOI 10.1097/RCT.0000000000000823
View details for PubMedID 30407249
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 DOI 10.12788/jhm.2908
View details for PubMedID 29394300
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
- 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 DOI 10.1136/postgradmedj-2016-134617
View details for PubMedID 28663352
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 DOI 10.1177/1559827615583643
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 Web of Science ID 000388955800005
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
- 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
- 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
- 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