1. < Message from the Chair

Central to our identity as an academic department of medicine is our unflinching commitment to learn, discover, improve what we do for our patients, and disseminate new knowledge. Our exceptional clinical faculty are also UCLA professors, who play important roles in training the next generation of physicians, while innovating in their delivery of care. To advance within our academic system, our faculty are expected to demonstrate excellence in A: Teaching; B: Professional competence; C: Creative Administrative, Academic and Scholarly Activities and D: University and Public Service. Details of these expectations that form the basis of promotion evaluations are summarized in the university’s Academic Personnel Manual (APM).  Here you will find a detailed list of creative activities that include contribution to educational curricula, lectures, publication of research, case reports, quality improvement, community outreach and many others. An important way that the UCLA Department of Medicine (DoM) is supporting our faculty’s creative and scholarly activities is to provide user friendly outlets through which our faculty can document and disseminate these activities. This week we celebrate the one-year anniversary of our peer-reviewed and globally indexed scholarly outlet: Proceedings of the UCLA Department of Medicine, announce the launch of our innovative platform UCLA Department of Medicine Clinical Insights, a new portal for narrative essays, clinical vignettes, quality improvement projects and other short-article formats. Finally, we celebrate our inaugural UCLA DoM Quality Improvement Symposium. Collectively these activities and initiatives are central to our department’s Strategic Plan to Lead in Innovation, Transform Care and Advance Health for All.

Happy One Year Anniversary, Proceedings!

It has been one year since we launched Proceedings of the UCLA Department of Medicine, our department’s journal for documenting faculty creativity, which is a digital publication on the Cureus platform. We have learned much from the 113 (and counting!) case studies and articles published so far — both in terms of medical knowledge and on how to develop a successful academic journal.

“It’s been a really enriching experience,” Ramya R. Malchira, MD, who serves as senior editor alongside Dianne S. Cheung, MD, MPH, said. “Helping our colleagues in the department of medicine refine their work and go through the steps of getting it through peer review and ultimately to publication has been really rewarding."

Dr. Malchira added that she was new to the editorial process prior to being appointed to her role. She is grateful for the guidance of Dr. Cheung and Proceedings Editor-In-Chief Michael E. Lazarus, MD, both of whom have extensive experience with the “other side” of academic publishing.

“This was new to me, and I was very nervous going into it,” Dr. Malchira said. “It’s strengthened not only my editorial judgement, but also my knowledge on how the publication process works.”

Dr. Malchira noted that those who have published in Proceedings commented that the process was more extensive than it was with the journal’s predecessor, which did not involve external peer review. Still, the outcome was worthwhile.

“When authors see the article transform from when it is submitted to when it gets published, they often tell us they’re glad they stuck with it,” Dr. Malchira said.

I am proud of all of you who have added to the body of clinical and scientific knowledge by publishing in Proceedings (including several of you who have published multiple times!), and I encourage you to continue to do so. Meanwhile, I am excited to share an update on “DoM Clinical Insights,” the companion publication to Proceedings that will greatly expand the ways our brilliant faculty can document their creativity. Read on to learn more! 

100^th Proceedings Article Documents Reactivation of Coccidioidomycosis 50 Years Later

In celebration of major milestones for Proceedings, I chose to highlight the exceptional work of the authors behind the 100^th publication, “A Case of Reactivated Disseminated Coccidioidomycosis in an Elderly Patient.” Primary care physicians Gabriela Rodriguez Melgoza, MD; Roya Mojarrad, MD; and Diana Sarkisyan, MD of UCLA Simi Valley Primary & Specialty Care did an outstanding job documenting and analyzing their observations on the case of an elderly patient who experienced an unusual reactivation of extrapulmonary disseminated coccidioidomycosis, a fungal infection, 50 years after he first contracted it.

“Dr. Rodriguez, Dr. Mojarrad and Dr. Sarkisyan stuck to the task and responded to multiple reviewers,” Dr. Lazarus said. “Dr. Cheung did an outstanding job of first draft suggestions too.”

The article details the trajectory of an 88-year-old Hispanic man who presented to Dr. Rodriguez with 10 days of pain, redness and swelling in his left wrist and right knee, along with a mild fever. This was in addition to a soft tissue mass on the back of his right upper arm that had been present for about a year but had recently begun growing to the point of discomfort. The patient said that he had been successfully treated for coccidioidomycosis infection in his right elbow 50 years earlier. His comorbidities included hypertension, type 2 diabetes mellitus, ischemic cardiomyopathy, aortic stenosis, and atrial fibrillation. He had previously undergone surgery for coronary artery bypass graft and transcatheter aortic valve replacement. 

The patient’s care team ordered a CT scan of his arm and found a mass filled with fluid, which they aspirated and sent for analysis. Cytology from the sample showed “rare fungal elements consistent with coccidiodomycosis;” fluid cultures eventually grew Coccidioides, the organism responsible for the infection. Meanwhile, duplex ultrasound of the swelling in his right knee found a non-occlusive deep vein thrombosis (DVT) of his femoral vein.

MRI of the patient’s arm showed that there was no infection in the bone. He was diagnosed with disseminated coccidioidomycosis and discharged on fluconazole 600 mg daily; he was already on a low dose of the blood thinner Eliquis, so the team raised his dose to treat the DVT. His disease was controlled with fluconazole for two years, until he died of heart failure.

The case was notable for several reasons, as the authors documented in their article. First, 60% of Coccidioides infection cases are asymptomatic; in the roughly 40% that are not, the infection is in the lungs. Disseminated infections like the one in this patient are seen just around 1% of the time. Typically, in those instances, the infection reaches the bone — in this case, the patient’s infection remained in the soft tissue.

The case’s most unusual feature was the infection’s reactivation after such a long period of latency. The literature suggests that Coccidioides is followed by lifelong immunity and that reinfection does not occur; most cases of reactivation were seen within two months after initial infection and were associated with immunodeficiency. Diabetes, late-stage pregnancy, therapies or diseases that cause one to become immunocompromised and being of African-American or Filipino descent are all associated with more severe or disseminated disease, as seen in this patient.

Dr. Rodriguez, Dr. Mojarrad and Dr. Sarkisan believe that the patient’s age and comorbid conditions — along with his sex, as Coccidiodes is more common in men than women — could explain why his infection reactivated so long after initial infection. The unusual presentation prompted them to share the case in Proceedings.

“It is important for physicians to recognize that Coccidioides can reactivate many years after the initial infection, particularly in older patients,” Dr. Rodriguez said.

Dr. Rodriguez appreciated Proceedings review process and found it an easy platform to navigate, which helps busy physicians get their articles published more quickly. She recommends it to others who feel compelled to share their clinical observations.

“I do feel like the peer review process improved my article,” she added.

Thank you to Gabriela, Roya, Diana, the team in Simi Valley who helped care for this patient, and our Proceedings editorial team for ensuring that this important case reaches other clinicians!

I am proud of all of you who have added to the body of clinical and scientific knowledge by publishing in Proceedings (including several of you who have published multiple times!), and I encourage you to continue to do so. Meanwhile, I am excited to provide more details on DoM Clinical Insights, the companion publication to Proceedings that will greatly expand the ways our brilliant faculty can document their creativity. Read on to learn more! 

Back in September I announced that the department would soon launch UCLA Department of Medicine Clinical Insights (DoMCI), a companion publication to Proceedings. I am pleased to share that it is live as of today, with the same leadership team at the helm — Editor-in-Chief Dr. Lazarus and Senior Editors Dr. Cheung and Dr. Malchira.

“This will be an opportunity for our clinicians who might be seeing some exciting pathology and cases to quickly write up something interesting without having to do extensive literature review and research they would normally do for Proceedings, Dr. Cheung said. “They’re quick, easy vignettes to teach a clinical pearl or two.”

DoMCI can be found on eScholarship, the University of California system’s open access publishing platform. It is not a replacement for Proceedings but represents an expansion of our creative outlets, serving as an additional home for diverse content that inform and educate. Moreover, the promotions review panels will recognize faculty contributions to DoMCI as evidence of creativity:

• Visual diagnosis pearls: Videos, gifs or images accompanied by explanations of no more than 650 words. These can have up to three faculty authors.
• Narrative medicine essays: Reflections on patient interactions that illuminate the lived experience of those who seek care in the DoM. These can have two authors.
• Quality and patient safety project summaries: Write-ups on quality improvement projects and their results. These can have three authors.
• Clinical reasoning cases: Problem-solving exercises to improve diagnostic reasoning. Clinical reasoning cases can have as many as five faculty authors.

“The different categories of publication types that we’re offering is in tune with modern publishing,” Dr. Lazarus aid. “The diversity and variation in the different kinds of publications will suit busier clinicians who may not necessarily have the time to do a full case report.”

Like Proceedings, DoM Clinical Insights is a way for faculty to document their creativity as they seek promotion. Content initially will not be indexed on PubMed. Still, it is not intended as a replacement for Proceedings. Dr. Malchira encouraged faculty to continue to think of Proceedings as the primary place to document your clinical scholarship.

“I think it's really helpful to have three or four people listed as authors — have a specialist, have a radiologist, a pathologist,” Dr. Malchira said. “That collaboration really improves the quality of the papers."

The first reports for publication in DoM Clinical Insights are already under review. For more information, please see this editorial by Dr. Lazarus, Dr. Cheung and Dr. Malchira. I look forward to learning from your submissions.

DoM Quality Symposium Highlights Our QI Rockstars

The DoM Quality team (DoM Quality) is a critical part of our patient care mission and is one of many reasons why we are nationally ranked in several DoM specialties. On Oct. 22, the team held its inaugural DoM Quality Symposium, an event to bring together QI LEADERS to share insights and highlight advances in care delivery, education, and research.

The symposium featured a keynote address, TED-style presentations, and interactive discussions, with a virtual broadcast for those who could not attend in person. I was fortunate to introduce the conference and welcome attendees alongside Dr. Dermenchyan, UCLA Health Chief Medical Officer for Ambulatory Care, Maria Han, MD, MBA, MS, and UCLA Health Chief Medical and Quality Officer, Robert A. Cherry, MD, MS, FACS, FACHE. A keynote address delivered by former Oracle Health executive Nasim Afsar, MD, MBA explored the potential of AI to augment clinicians’ ability to deliver high-quality, efficient, and compassionate care. The symposium then continued with several thought-provoking presentations from DoM Quality team members.

The presentations were organized into three themes: ambulatory care quality, inpatient care quality, and research and education. During the ambulatory care segment, Jeff T. Fujimoto, MD, MBA, Medical Director of Ambulatory Care, and Sylvia Lambrechts, MPH, MA, CPHQ, CLHP, Senior Program Manager who leads QI initiatives for DoM Quality illustrated how closing care gaps reflected in quality metrics translates into meaningful patient outcomes. Pooya I. Bokhoor, MD, and David J. Cho, MD, MBA, Medical Directors for the Cardiology and Subspecialty Quality Programs, shared how aligning performance incentives has enhanced cardiovascular care, while Nika M. Harutyunyan, MD, CPHQ , Medical Director of Ambulatory, and Cory Hedwall, MBA, CPHQ, Program Manager, described how the IMPACT program expands team-based models to mitigate clinician burnout and improve patient access.

The inpatient care quality theme highlighted how data-driven learning and care redesign are transforming hospital-based care. Erin P. Dowling, MD, FACP, CPHQ, Medical Director of Inpatient Quality, and Maryann Elegonye, BAS, Quality Incentives Program Manager, discussed building an inpatient quality portfolio through peer alignment and transparent performance data. Wendy M. Simon, MD, FHM, CPHQ, Medical Director of Inpatient Quality, and Frances Schiff, BSN, RN, CPHQ, Inpatient Peer Review RN, presented on rapid mortality review as a framework for real-time learning through clinical debriefing. Finally, Richard K. Leuchter, MD, founder of the UCLA Next Day Clinic (NDC) and Danielle, NDC program manager, shared how the clinic is reimagining high-acuity care outside hospital walls care to decompress the ED and save hospital bed days.

The research and education theme underscored the importance of developing the next generation of quality leaders and embedding improvement into professional culture. Undergraduate presenters from The Healthcare Improvement and Innovation in Quality (THINQ) Collaborative, a UCLA program for undergraduates and recent graduates interested in healthcare quality improvement, described their work and experiences. THINQ Executive Director Sristi Palimer, BS, and Associate Director Michael Lim spoke about the essential role of early QI education in seeding long-term systems thinking and quality improvement efforts . They were followed by presenters Yaroslav A. Gofnung, MD, CPHQ, Peer Coaching Program Director, and Carolyn Goh, MD, FAAD, Associate Director, conducted a mock coaching session and shared how the program is addressing workforce challenges and supporting physician well-being. Hengchen Dai, PhD, co-director of the UCLA Nudge Unit, concluded the program with a presentation on leveraging behavioral interventions in healthcare to make the right choice the easy choice for patients and clinicians.

“It was energizing to see so many quality experts and frontline practitioners come together in one room. The engagement and curiosity were palpable,” Danielle said. “I hope attendees left inspired to bring new ideas back to their teams and strengthen connections across divisions. After all, that’s how real system-wide improvement takes root."

Dr. Dermenchyan was delighted to see how engaged attendees were, both in the live audience and online. The enthusiasm continued long after the day ended, with several participants reaching out to explore job opportunities and to inquire about adapting DoM Quality programs within their departments or partnering on future projects.

“The feedback we received reflected exactly what we hoped to achieve: participants described the symposium as relevant, inspiring, and practical, noting how speakers connected theory to real-world clinical examples,” she said. “My hope is that everyone left with renewed purpose and at least one new idea to advance quality and patient safety in their own sphere."

Congratulations and thank you to Dr. Dermenchyan, Danielle, and all of our exceptional DoM Quality Team for organizing such an impactful conference!

Dale

P.S.

As many of you travel or plan for Thanksgiving celebrations, let me wish you a meaningful time with your families, safe travel and good digestion. For those of you who will be in the hospital on Thanksgiving Day, thank you for your service.

This engendered significant interest, including some genuine curiosity as to whether these were tomatoes or eggplants! I promised to share what they look like when we sliced them, so here are pictures of the first one that we ate this weekend. As they ripened, they remained dark purple on the bottom and red on the top.

As I sliced through it, I waxed poetic and declared to my wife, no matter what the color of our skin is, we all bleed the same red inside.

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