Master Clinicians: Recognizing Clinical Excellence

reprinted from Issue 23, Fall 2016 of Frontiers of Medicine (PDF)

Each year, the Department of Medicine recognizes outstanding physicians who have exceptional knowledge, superior teaching and communication skills, and an ability to provide compassionate, appropriate, effective, and high quality patient care. The newest members of the Council of Master Clinicians are profiled here.

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.

Family Man

As a child, oncologist Thierry Jahan, MD, remembers that his mother was always tired. After doctors diagnosed her with pancreatitis and performed surgery, she was able to climb to the top of the Statue of Liberty with her children. "As an eight- year-old, I said, ‘I want to do what those doctors do – I want to give another kid his mom back.’"

Jahan grew up in France, Venezuela, and New York, and started medical school in Paris. The competition was cutthroat – less than 10 percent of first- year students advanced to the second year, and troublemakers threw dead lab mice at one professor to disrupt her lecture. Jahan enthusiastically transferred to the American educational system, where he got hooked on hematology/ oncology in medical school. "It was an extraordinary emotional and intellectual challenge, and the field was starting to move in a good direction," he said.

Soon after joining the faculty in 1994, Jahan and thoracic surgeon David Jablons, MD, co-founded the UCSF Thoracic Oncology Program, building it into a leading program for lung cancer, mesothelioma and other thoracic malignancies.

"Dr. Jahan has a gift for balancing the realities of the delivery of treatment options with an impeccable, warm, engaging bedside manner," said Eric J. Small, MD, FASCO, chief of the Division of Hematology and Oncology, Stanford W. and Norman R. Ascherman Endowed Chair, and Doris and Donald Fisher Distinguished Professor in Clinical Cancer Research.

"We offer solutions and possibilities," said Jahan. "I tell patients, ‘This is what the average patient can expect, but I’m shooting for the good side of the bell curve.’ I empower them to make decisions about how they want to face their disease."

When his own father was diagnosed with mesothelioma, Jahan suggested a recently approved drug that did not increase survival but helped reduce symptoms. His father savored one last holiday season with his children and grandchildren, then died two weeks later. "That experience was painful but extraordinarily informative," said Jahan. "I have a pretty good idea of what patients and families go through, and it helped shape how I do things."

In addition to leading many clinical trials, Jahan helped draft the National Comprehensive Cancer Network guidelines for lung cancer treatment, used by Medicare and most insurance companies to make coverage decisions. He also served on the UCSF Committee on Human Research and the Data Safety Monitoring Committee, helping ensure that clinical trials are conducted safely and ethically.

Jahan is the rare physician who enjoys conducting research audits, poring through patient charts in windowless rooms. "Rather than telling people, ‘You’re doing a bad job,’ I see it as a teachable moment – ‘Here’s what you’re doing well, and here’s how you can do better,’" he said.

Jahan enjoys playing ice hockey and attending the San Francisco Symphony, and is married to pediatrician Valerie Jahan, MD. They have three grown children: Kenneth, Lillian and Robert.

Embracing the Story

"The final years of life often come with difficulties, including physical or cognitive decline," said geriatrician Helen Kao, MD. "I try to help my patients live rich lives, make their disabilities more tolerable, and prepare them for the last step of their journey."

Growing up, Kao loved stories and dreamed of becoming a writer. But after college, she worked at the Harvard School of Public Health for a doctor who encouraged her to become a physician. As a medical student and resident at UCSF, her fascination with life stories drew her to geriatrics, which she describes as "very story-driven."

"What I do is 50 percent medical and 50 percent everything else," said Kao. For example, for a dementia patient with balance problems who loved to bowl, she found a disability bowling league near his hometown. "Just like I need to understand what a medication does, I need to know what’s available in someone’s community to optimize their well-being," said Kao. "I really like digging into that."

She has a particular interest in dementia, which affects a growing number of seniors and impacted her own grandparents. "If the patient is not disturbed by their hallucinations, we encourage caregivers to be in their loved one’s reality," said Kao. "It’s much less distressing than constantly telling them, ‘No, it’s not 1942,’ or ‘There are no airplanes in the house.’"

Her accomplishments include co-founding the UCSF-UC Hastings Medical Legal Partnership for Seniors, which trains law students how to handle legal issues affecting elders’ health, such as end-of-life treatment. She also served as medical director of the UCSF Housecalls program and founded the UCSF Geriatric Transitions program (later reconfigured into UCSF Bridges).

These programs provide primary, transitional and palliative care to homebound patients, and mobilize quickly if a team member notices a potential health crisis brewing. "I can ask my nurse practitioner to do an urgent visit, get my patient care coordinator to reach out to the home health agency, and have my social worker initiate an intervention – all of which seamlessly unfolds within 24 hours and averts the patient having to go to the emergency room," said Kao.

"Dr. Kao possesses exceptional skills as a compassionate and caring clinician and is a pioneer in health systems innovation, working tirelessly to improve how we care for our frailest, most vulnerable patients," said Louise C. Walter, MD, chief of the Division of Geriatrics.

One piece of advice has been particularly helpful in building these programs: do things in series when you cannot do them in parallel. "Don’t try to do everything at once," said Kao. "Do things sequentially if that’s the only way to accomplish them."

She is now applying that advice in a new arena. In July, she moved to Corvallis, Ore., to join her new husband, emergency room physician Gabriel Ledger, MD; they are expecting their first child. Kao continues to serve as a UCSF volunteer faculty member, works part- time at Oregon Health and Science University, and hopes to build a geriatrics and dementia care program in the Corvallis area.

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