Year 5. August 24. Science Monday – Trainee Scholarship
Our commitment to lead in innovation, transform care and advance health for all, is inclusive of all members of the UCLA Department of Medicine (DoM). Each year, we recruit some of the most compelling trainees from across the country who entrust their careers to us. We are not only obligated to ensure that they become highly qualified internal medicine specialists, but importantly we seek to leverage their curiosity with the rich mentorship available at UCLA to advance discovery in their own right. As such, I look forward to seeing the publications in the scientific literature that arise from the work of our trainees. Today, I select a few of the recent publications of our residents and fellows that represent a sample of their outstanding productivity.
These examples of scholarship spans the continuum of care, from improving access and delivery to advancing clinical decision-making and understanding the patient experience.
Connecting Patients to Care When it Mattered Most
One of the enduring lessons of the COVID-19 pandemic is that innovation in patient care must be accompanied by equity. As health systems rapidly adopted telemedicine to maintain access to care, important questions emerged about whether these new approaches would serve all patients equally. In her recent publication, Primary Care Visit Trends in a Public Safety Net Health System During the COVID-19 Pandemic, Cristina Valdovinos, MD, fellow in the UCLA National Clinician Scholars Program, examines how telehealth affected access to primary care among a diverse safety-net patient population that included Medicaid beneficiaries and patients with limited English proficiency (LEP). The study was co-led by Alejandra Casillas, MD, MSHS, associate professor in the division of general internal medicine and health services research.
Dr. Valdovinos and her colleagues analyzed more than 400,000 primary care visits across three years in a large urban safety-net health system. Their findings showed that telehealth played a critical role in sustaining access to care throughout the pandemic. Importantly, telephone visits emerged as the primary driver of that access, serving patients who may have faced barriers to video-based care.
During this time, many were concerned that the rapid shift to digital health could widen existing disparities and contribute to a “digital divide.” Dr. Valdovinos’ research provided valuable insight into how safety-net systems adapted to meet patients where they were. The findings suggest that access to technology and digital infrastructure may be more important barriers to telehealth participation than language alone.
A unique strength of this work is its distinction between telephone and video visits. Many previous studies grouped these modalities together under the broad category of telehealth. By examining them separately, Dr. Valdovinos and her team demonstrated that telephone visits accounted for most telehealth utilization among underserved patients and were essential to maintaining continuity of care during the COVID-19 pandemic.
The study's findings have important policy implications. Current federal reimbursement policies, such as the Centers for Medicare & Medicaid Services (CMS) waiver, continue to support payment parity for audio-only telehealth visits. However, the future of CMS waiver remains uncertain. This research highlights why maintaining access to telephone-based care is critical for many safety-net patients and underscores the need for continued study of telemedicine's effects on health outcomes, quality and cost.
Reflecting on the significance of the work, Dr. Valdovinos notes, "Our findings highlight how important telephone visits were in helping our safety-net patients stay connected to primary care during the pandemic. It's a reminder that not everyone has equal access to digital health tools like video visits. As digital health continues to evolve, investing in the right technology and infrastructure for safety-net settings is essential."
We congratulate Dr. Valdovinos on this important contribution to health services research. Her work advances our understanding of equitable access to care and exemplifies the commitment of our trainees to improving health outcomes for underserved communities.
Publication: Primary Care Visit Trends in a Public Safety Net Health System During the COVID-19 Pandemic. Frontiers in Public Health.
Closing the Gap Between Evidence and Care
"Dashboard-based interventions, by their nature, reach vulnerable patients who fall through the cracks." – Qicong Sheng, MD
That observation from Qicong Sheng, MD, third year internal medicine resident, captures the central challenge addressed in his recent publication, Dashboard-Directed Intervention to Improve Guideline-Directed Heart Failure Therapy for Veterans. Despite clear evidence supporting guideline-directed medical therapy (GDMT) for heart failure, many patients never receive these treatments in routine clinical practice. Dr. Sheng's work explores how health systems can use existing data and technology to help close that gap.
The study evaluated the Dashboard Clinic at the West Los Angeles VA, where cardiology fellows use a clinical dashboard to identify high-risk patients with heart failure who are not receiving recommended therapies. Rather than relying solely on traditional clinic visits, fellows proactively contact patients through telehealth, review treatment opportunities and initiate GDMT when appropriate. Over the course of one year, 163 patients received the intervention, resulting in a significant increase in GDMT uptake.
At its core, the study highlights a shift from reactive care to proactive care. Population health dashboards are now common within many health systems, yet they often remain underutilized. This work demonstrates how those tools can be leveraged to identify care gaps, reach patients who might otherwise be lost to follow-up and ensure that evidence-based therapies are delivered more consistently.
These implications extend beyond heart failure management. Dr. Sheng and his colleagues propose a model that could be adapted to other specialties and health systems, using data-driven approaches to improve care for vulnerable populations. The Dashboard Clinic also serves as an innovative educational platform, providing trainees with hands-on experience in population health management, quality improvement and systems-based care.
As health care continues to embrace data-driven approaches, studies such as this, help illustrate how technology can support better implementation of proven therapies. By identifying patients who might otherwise be overlooked and connecting them to appropriate treatment, dashboard-based interventions have the potential to improve outcomes while transforming the way care is delivered.
Publication: Dashboard-Directed Intervention to Improve Guideline-Directed Heart Failure Therapy for Veterans. JACC: Advances.
Closing the Follow-Up Gap in Colorectal Cancer Screening
Colorectal cancer screening saves lives, but only when patients complete the full screening pathway. For individuals with an abnormal fecal immunochemical test (FIT), timely follow-up colonoscopy is critical for detecting and preventing colorectal cancer. Yet many patients never receive this critical next step in care. In his recent publication, Area Deprivation Index Predicts Colonoscopic Follow-up After Abnormal Immunochemical Testing for Colorectal Cancer Screening, Yousif Arif, MD sought to better understand why.
Studying 1,083 patients with abnormal FIT results, Dr. Arif and his colleagues examined whether neighborhood-level disadvantage influenced the likelihood of completing a recommended follow-up colonoscopy. They found that only about half of patients completed a colonoscopy within six months of an abnormal test result. More importantly, patients living in increasingly disadvantaged neighborhoods were significantly less likely to undergo follow-up colonoscopy at both six and twelve months.
Previous studies have attempted to explain disparities in follow-up screening using individual measures such as income or employment status, often with inconsistent results. This study took a different approach by using the Area Deprivation Index (ADI), a composite measure that incorporates income, education, employment and housing quality to assess neighborhood disadvantage. Using this multidimensional tool, the investigators identified a clear stepwise relationship between neighborhood deprivation and screening completion.
As Dr. Arif explains, "Our study shows that where someone lives is a powerful, measurable predictor of whether patients get the follow-up colonoscopy they need after an abnormal fecal immunochemical test result. By using tools like the Area Deprivation Index, already built into our electronic health records, we can identify at-risk patients early and direct outreach where it's needed most."
The findings have important implications for both patient care and health equity. Because ADI scores are already available within many electronic health records, health systems may be able to use this information to proactively identify patients at risk of missing follow-up care. Targeted interventions such as patient navigation, reminder programs, transportation assistance or enhanced outreach could help address barriers before patients are lost in the screening process.
Perhaps most importantly, this work reminds us that access to screening alone is not enough. To realize the full benefits of colorectal cancer prevention, health systems must ensure that patients can successfully navigate every step that follows. By identifying a practical and scalable way to recognize patients at greatest risk for incomplete screening, Dr. Arif's research offers a promising strategy for improving outcomes and advancing health equity.
Publication: Area Deprivation Index Predicts Colonoscopic Follow-up After Abnormal Immunochemical Testing for Colorectal Cancer Screening. Gastroenterology Report.
Next, several of our trainees also addressed important clinical questions that may influence how we assess risk and deliver care in the future.
Looking Beyond the Scale: Rethinking Cardiovascular Risk
For many patients and clinicians, the number on the scale is often viewed as a key measure of health. But what if weight alone does not tell the whole story?
That question is at the center of a recent publication by Aarti Kumar, MD, a recent graduate from our residency program and a fist-year cardiology fellow, whose research suggests that body composition may be a more meaningful predictor of long-term cardiovascular health than body mass index (BMI) alone. In Body Composition Changes During Cardiac Rehabilitation and Long-Term Cardiovascular Outcomes in Patients with Coronary Artery Disease, Dr. Kumar and her colleagues examined how changes in body fat and lean muscle mass during cardiac rehabilitation relate to future cardiovascular outcomes.
The study followed more than 1,200 patients with coronary artery disease who participated in a cardiac rehabilitation program. While body mass index (BMI) has long been used as a standard measure of obesity and cardiovascular risk, it cannot distinguish between fat and muscle. By evaluating changes in body composition before and after rehabilitation, the investigators were able to explore whether these more detailed measures provided additional insight into long-term health outcomes.
Their findings were striking. Patients who experienced increases in body fat percentage faced a significantly greater risk of future cardiovascular events and death, while changes in BMI showed no meaningful association with outcomes. The results suggest that what makes up a person's weight may be more important than the weight itself.
The research also points to a broader opportunity in cardiovascular care. Cardiac rehabilitation has traditionally focused on improving fitness and supporting weight management. Dr. Kumar's findings suggest that preserving or increasing lean body mass while reducing excess body fat may be a more meaningful goal than weight loss alone. Incorporating body composition measurements into routine clinical assessments could help clinicians better understand risk and tailor treatment strategies for patients with coronary artery disease.
As Dr. Kumar notes, "BMI is only one part of the picture when it comes to cardiovascular health. Our findings suggest that changes in body composition, particularly increases in body fat, may provide important information about long-term risk that BMI alone does not capture."
This work contributes to a growing body of research that challenges traditional approaches to assessing cardiovascular risk. By looking beyond the scale, Dr. Kumar's study offers a more nuanced understanding of how changes in body composition may influence long-term outcomes and provides new direction for future research and patient care.
Publication: Body Composition Changes During Cardiac Rehabilitation and Long-Term Cardiovascular Outcomes in Patients with Coronary Artery Disease. American Heart Journal Plus: Cardiology Research and Practice.
The Value of Getting Heart Failure Therapy Right
Few advances in cardiovascular medicine have had a greater impact on patients with heart failure with reduced ejection fraction, than the development of four foundational medication classes (angiotensin receptor–neprilysin inhibitors (ARNI), β-blockers, mineralocorticoid receptor antagonists (MRAs), and sodium–glucose cotransporter 2 inhibitors (SGLT2i) that improve survival and reduce hospitalizations. Yet many eligible patients do not receive all of these therapies, in part because of concerns about medication costs. In his recent publication, Cost Offset With Quadruple Therapy for Heart Failure, Internal Medicine Resident Mohammad Keykhaei, MD, MPH examined an important question: can the costs of comprehensive heart failure treatment be offset by the hospitalizations it helps prevent?
Under the mentorship of Professor Gregg C. Fonarow, MD, Dr. Keykhaei and colleagues combined real-world Medicare spending data from more than 50,000 older adults hospitalized with heart failure with evidence from major clinical trials. They compared current patterns of incomplete treatment with optimal use of all four recommended medication classes and estimated the resulting impact on healthcare spending.
The findings highlight the substantial economic value of evidence-based heart failure care. The investigators estimated that expanding treatment to include all four recommended medication classes could reduce hospitalization-related spending by approximately $9,780 per patient during the following year. Whether treatment ultimately produced net savings depended on the specific medications selected and their cost, but many lower-cost combinations were projected to fully offset their expense through reductions in hospitalizations.
These findings challenge a common assumption in clinical practice. While medication costs are often viewed as barriers to comprehensive therapy, the study suggests that the more relevant question may be how to identify affordable treatment options within each recommended class, rather than whether patients should receive these therapies at all. The work underscores the importance of considering the total cost of care, including preventable hospitalizations, when evaluating treatment decisions.
The study also offers a practical message for clinicians and health systems. As Dr. Keykhaei notes, medication cost should not automatically prevent eligible patients from receiving comprehensive heart failure therapy, particularly when lower-cost alternatives may be available within the same therapeutic class. By improving access to evidence-based treatment, health systems may simultaneously improve patient outcomes and reduce healthcare utilization.
Unlike many studies that focus exclusively on clinical efficacy, this work highlights the importance of value in healthcare delivery. As increasingly effective therapies become available, understanding how to deliver them in a way that is both clinically beneficial and economically sustainable will remain an important challenge.
Publication: Cost Offset With Quadruple Therapy for Heart Failure. JAMA Cardiology.
Beyond Gluten Avoidance: Identifying Restrictive Eating Patterns
For patients with celiac disease and non-celiac gluten sensitivity, avoiding gluten is an essential part of treatment. Yet an important question remains: when does necessary dietary awareness begin to affect a person's broader relationship with food?
That question was explored in a recent collaborative study to which Bethlehem Michael, MD, MPH, contributed prior to joining UCLA. The study examined symptoms of avoidant/restrictive food intake disorder (ARFID) among children and adults with celiac disease and non-celiac gluten sensitivity. ARFID is characterized by restrictive eating patterns that can lead to nutritional deficiencies, impaired growth, weight loss or psychosocial difficulties, but unlike other eating disorders, it is not driven by concerns about body image.
The investigators found that ARFID symptoms were present in approximately one in five patients with gluten-related disorders. Fear of negative consequences from eating was the most common reason for food restriction, followed by lack of appetite. Patients with ARFID symptoms were more likely to have lower body mass index, a history of weight loss or poor weight gain, and additional dietary restrictions beyond gluten avoidance. Among children, ARFID symptoms were also associated with impaired linear growth.
Importantly, the study found no relationship between ARFID symptoms and the duration of adherence to a gluten-free diet or markers of celiac disease activity. These findings suggest that maladaptive eating patterns may occur independently of how well a patient's underlying disease is controlled.
What makes this work particularly valuable is its effort to distinguish medically necessary dietary restriction from potentially harmful patterns of food avoidance. Previous studies often relied on screening questionnaires that could not easily differentiate appropriate caution around gluten exposure from broader restrictive eating behaviors. In contrast, this study used detailed medical record review and DSM-5 criteria to more carefully assess whether restrictive eating patterns extended beyond what was medically required. The study also included both pediatric and adult patients and is among the first to examine ARFID symptoms in individuals with non-celiac gluten sensitivity.
"Following a gluten-free diet requires patients to pay close attention to what they eat. Sometimes necessary dietary restrictions can evolve into maladaptive patterns of food restriction," Dr. Micheal notes. "Our study highlights the importance of looking beyond gluten avoidance and asking patients about their overall relationship with food, particularly when there are concerns about weight loss, growth or additional dietary restrictions."
The findings highlight an important message for clinicians caring for patients with gluten-related disorders. Beyond assessing adherence to a gluten-free diet, providers should consider asking about other food restrictions, changes in weight or growth, and the reasons patients avoid certain foods. Early recognition of maladaptive eating patterns may help prevent nutritional complications and support the overall well-being of patients navigating lifelong dietary restrictions.
Publication: Avoidant/Restrictive Food Intake Disorder Symptoms in Patients with Celiac Disease and Non-Celiac Gluten Sensitivity. Nutrients.
The accomplishments exemplified in this week’s newsletter reflect the remarkable dedication of our trainees to scholarship, that permeates our training programs. Conducting research, publishing scholarly work and providing exceptional patient care require curiosity, perseverance and an extraordinary commitment of time and energy. I also want to highlight the strengthening of the research pathway in our medicine residency program under the leadership of Risa M. Hoffman, MD, Russell G. Buhr, MD, PhD, Berkeley N. Limketkai, MD, PhD and Wendy M. Simon, MD. It is our intent that all our trainees avail themselves of structured mentorship that will provide them the opportunity to receive formal mentorship for those who are keen to explore a career in research during residency.
Supporting the Whole Trainee
The accomplishments highlighted throughout this week’s newsletter reflect the remarkable dedication of our trainees. Conducting research, publishing scholarly work, and providing exceptional patient care require curiosity, perseverance, and an extraordinary commitment of time and energy.
As we celebrate these achievements, we also recognize the importance of fostering a training environment that supports well-being and community. Excellence in medicine is sustained not only through scholarship and clinical training, but also through meaningful opportunities to connect with colleagues, recharge and support one another.
We are grateful to the faculty, staff and chief residents who invest their time and creativity in organizing wellness activities for our trainees. These efforts help strengthen the sense of community that is essential to a positive training experience and remind us that professional growth and personal well-being go hand in hand.
A recent wellness lunch hosted at the West LA VA provided one such opportunity for trainees and colleagues to come together outside of their usual clinical responsibilities. We extend our sincere thanks to Mondo Medina, health professional education specialist, the internal medicine chief residents, Edward S. Lee, MD and Claire E. Drolen, MD for facilitating this year’s wellness lunch.
Please enjoy a few photos from the wellness lunch below.
Internal medicine residents enjoying a sunny afternoon at the West LA VA wellness lunch.
Dale
P.S.
My mom is spending a few weeks with us in LA. Of course I am happily participating in her favorite past-time.
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