Master Clinician: Jonathan Graf, MD

Rheumatology Sleuth

"Diseases have personalities – they each behave and look a certain way," said rheumatologist Jonathan Graf, MD. "I encourage trainees to get to know human diseases as they would know their patients. Getting to know a disease’s personality and when a set of symptoms does or doesn’t fit can often be more helpful in diagnosing and treating patients than memorizing lists."

This approached helped him when he saw a patient in the Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) rheumatology clinic with an unusual combination of skin lesions and autoantibodies. By piecing together symptoms, patient history, lab results, and medical literature, Graf and his colleagues landed on the likely cause: levamisole, a livestock deworming agent sometimes used to cut cocaine. They developed a urine test for levamisole, subsequently identified many other patients with this condition, and published several papers about this new disease.

Graf is interested in translational research, moving laboratory discoveries into the clinic to help patients. He directs the UCSF Rheumatoid Arthritis (RA) Observational Cohort, which has enrolled more than 830 patients at UCSF and ZSFG. The cohort collects clinical information and blood samples from participants, making this information available to researchers at UCSF and beyond and jump-starting investigations that seek to improve treatment of patients with RA.

His own research focuses on cardiovascular risk in RA patients. "The inflammatory response is great if you’re bitten by a tiger, but becomes maladaptive if it persists beyond an acute crisis," said Graf. RA patients have chronic inflammation, which damages the body, including the lining of blood vessels – which is linked to increased risk of heart attack and stroke. Even RA patients whose joint swelling is well controlled appear to be at increased risk. He and his colleagues are testing whether offering advanced therapies to patients currently on standard medications leads to improved blood vessel function.

Graf is an outstanding diagnostician and teacher. "His ability to pick up on key points, draw upon his grasp of clinical medicine, and reason his way to the correct diagnosis is uncanny," said John Imboden, MD, chief of the ZSFG Division of Rheumatology, Alice Betts Endowed Chair for Research in Arthritis, and a Master Clinician himself. "He also has a remarkable ability to make complicated issues intelligible to others."

Graf enjoys providing comprehensive care for patients. "Our medicines have gotten really good, so we can often help with their pain, fatigue, and other symptoms," he said. "I also make sure that they’re getting sleep, exercise, physical and psychological therapy, and home support. As they go through life, we’ll be there for them, too."

Graf is married to Jessica Graf, a rabbi. Together they have two young children, Arielle and Zachary, and enjoy hiking and traveling.