2013-2014 Master Clinicians: Recognizing Clinical Excellence

reprinted from Issue 17, Fall 2013 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.

The Most Important Procedure

Dr. Gurpreet Dhaliwal
Associate Clinical Professor
Site Director, Internal Medicine Student Clerkships,
San Francisco Veterans Affairs Medical Center

Listen to Dr. Dhaliwal's Podcast

Gurpreet Dhaliwal, MD, grew up listening to NPR's "Car Talk," and recently started downloading podcasts of the auto mechanics. lively call-in show.

"As soon as I started listening after I became a doctor, I said, 'These guys are master diagnosticians!'" says Dhaliwal, who cares for patients in the San Francisco Veteran Affairs Medical Center's (SFVAMC) emergency department, hospital and clinic. "someone brings a very complicated machine to them. There's extensive history taking. They are quite skilled in what they do, and you can.t help notice how much they enjoy doing it."

Dhaliwal analyzed the parallels between "Car Talk" and physicians in the Journal of the American Medical Association, drawing on his own passion for diagnosing disease. He is nationally renowned for his ability to solve difficult clinical cases, often before live audiences. A recent New York Times article stated, "To observe him at work is like watching Steven Spielberg tackle a script or Rory McIlroy a golf course."

"His command of internal medicine is truly breathtaking, his reading of the recent scientific literature is encyclopedic, and his application of it all? Oslerian," says Lawrence M. Tierney, Jr., MD, associate chief of the medical service at the SFVAMC, referring to Sir William Osler, revered by many as the founder of internal medicine.

How did Dhaliwal get so good? First, he constantly builds his knowledge base. "People are fond of saying, 'You can look it up on the Internet,' but we will always instinctively first try to match a patient's symptoms with the knowledge that is already stored on the hard drive of our brains," he says. Second: practice, practice, practice. "It's literally like a musician doing rehearsal, where you.re putting your brain through the paces of problems that come in the ER or the hospital ward," says Dhaliwal.

Perhaps most importantly, he pushes himself to improve - for example, checking the electronic medical record to follow up on patients he recently treated. "It's one of the most humbling things - without a doubt, many of them wind up having something else than I thought," says Dhaliwal. "This may be the key to reaching our maximal diagnostic potential: finding the place where we can still learn something, even from a condition we've seen many times. When people study expert performance, the common theme is possessing the 'beginner's mind' and habitually asking the question, 'What am I doing to get better?'"

A beloved teacher, he also co-chairs the education committee for the Society to Improve Diagnosis in Medicine, and hopes to broaden the "cognitive apprenticeship" model of teaching diagnosis. "Diagnosis is our most important procedure," he says. "My ultimate goal is for diagnosis, clinical reasoning and cognitive psychology to become a basic science for medical students and residents, just like anatomy or physiology."

Dhaliwal and his wife, Ritu Patel, MD, a pediatric hospitalist at Kaiser Permanente in Oakland, enjoy biking in Golden Gate Park with their two young sons, Niraj and Tejbir.

Trust and Collaboration

Dr. Dan Null
Health Sciences Clinical Professor
Medical Director, General Internal Medicine Practice, UCSF-Mount Zion Medical Center
Medical Director of Clinical Operations, Division of General Internal Medicine

Listen to Dr. Null's Podcast

Dan Null, MD, grew up on a farm in Pennsylvania, helping his family raise chickens, cattle and alfalfa. That work ethic serves him well as an internist with more than 1,000 patients - including many UCSF faculty and staff.

Earning the trust of his patients is the foundation of all his work. "You do it the way you establish any other kind of important long-term relationship," says Null. "Give them your attention, show them respect and make eye contact. Being patient is an essential quality. Sometimes you've just got to wait a little bit longer for a patient to reveal what it is they need to reveal. At the same time, you need to think as you're listening. Even as the patient is letting the story unfold, you're already formulating your follow-up questions."

Null identifies what motivates each patient, and helps him or her set realistic goals. "For example, with obesity, we look at the chart and see that their weight has been going up incrementally," says Null. "I always tell people, the first measure of success is if you stop gaining weight. That's a victory! Let's do that and celebrate that, and then we can work on additional changes. It's important to break it down into manageable steps. What do they have the bandwidth to take in, in their busy lives?"

"He is willing to care for the most complicated patients, and always willing to go the extra mile," says Robert B. Baron, MD, MS, associate dean for Graduate and Continuing Medical Education. "His patients adore him."

Null has spearheaded behind-the-scene efforts to improve care for all primary care patients, including championing the implementation of APeX, UCSF's new electronic medical record system. "This has been the most disruptive, yet most beneficial transformation that I've experienced since starting medicine," says Null. "It's a tremendous tool for primary care and management of chronic disease. You can tilt the screen towards the patient and graph out their weight, or pull up images to talk about their ear problem. With MyChart, the patient portal, there's much more interaction with patients in between visits. I can manage someone's blood pressure through back-and-forth emails. If I had to do everything through phone calls, I couldn't come close to doing it."

He has also led the development of a team approach to care - an integral part of the patient-centered medical home, in which groups of doctors, nurses and other health professionals collaborate to provide integrated care to patients.

Null loves teaching trainees, and emphasizes the importance of collaborating with patients. "Put the options in front of patients and help them choose, as opposed to dictate what they're going to do," advises Null. "It's really a privilege to be allowed to help them with this very important part of their life."

Null lives in the East Bay with his partner, Karen Williams, an artist. He is an enthusiastic volleyball dad to his teenaged daughter, Gemma.

Patients as Teachers

Dr. Jonathan Terdiman
Professor of Clinical Medicine and Surgery
Chief, Gastroenterology Service, UCSF Medical Center
Director, Hereditary Gastrointestinal Cancer Prevention Program
Program Director, Gastroenterology Fellowship Training Program

Listen to Dr. Terdiman's Podcast

"My basic approach to medicine is to have humility," says gastroenterologist Jonathan Terdiman, MD. "The best teachers are the patients. If you listen to their stories, common themes start to emerge and lessons can be learned that are not necessarily reported in the scientific literature. At first the lessons are fragmented, so if you're not really in the game regularly seeing patients, you're going to miss them."

Terdiman founded the UCSF Colitis and Crohn's Disease Center, which treats patients with Inflammatory Bowel Disease (IBD) - a group of often painful and debilitating conditions that occur when the immune system damages the intestine through chronic inflammation. "His expertise in inflammatory bowel disease has no equal in the state of California, and he is widely recognized as one of the country's leaders in his field," says UCSF gastroenterologist John P. Cello, MD.

"Over and over, patients would say, 'I'm on this diet, and this seems to really help me,'" says Terdiman. "You hear it too often for there not to be some kernel of truth in it. A lot of times, the medical community says, 'It's a coincidence.' Now we're beginning to understand that diet plays a critical role in intestinal inflammation, and serious science is catching up to these patient observations."

Inspired by these clues, Terdiman and his colleagues are now studying the relationships among diet, inflammation and the microbiome - the complex ecosystem of bacteria living in the intestine and other parts of the body. They are also starting clinical trials of microbial reconstitution therapy, in which bacteria from a healthy donor's stool is transplanted into the colon of a patient with disease. "What actually gets transferred is an almost colorless, odorless effluent," says Terdiman. "It's the essence of stool, which is the bacteria. Those bacteria take up residence and grow, and it changes your intestinal microbiome pretty drastically and quickly, leading to a reduction in inflammation."

Terdiman also founded and directs the Hereditary Gastrointestinal Cancer Prevention Program, which uses genetic tests to assess risk and prevent patients from developing genetically related forms of gastrointestinal cancer, especially colon cancer. "The key to saving lives in hereditary cancer is that when you identify someone with it, you have to get the message out to the rest of the family," says Terdiman. Recently, the program launched KinTalk, a secure, web-based tool which allows families to share important health information - including family trees and results of family members' genetic testing.

"The thing that I get the most pleasure from is direct patient care," says Terdiman. "It's a great honor, that someone is asking you to help them."

Terdiman is married to Madhulika Varma, chief of the Section of Colorectal Surgery at UCSF. Together they have two young daughters, Mira and Joya.

Keep Getting Better

Dr. Lisa Winston
Professor of Clinical Medicine
Hospital Epidemiologist, San Francisco General Hospital
Vice Chief, Inpatient Medical Services, SFGH

Listen to Dr. Winston's Podcast

"I love talking to patients," says Lisa Winston, MD, a hospitalist and infectious diseases specialist. "By investing time in the relationship and building up enough trust, we can get the real story. To hear them describe their illnesses, and then hopefully be able to reassure them and turn those stories into something that makes sense from a medical perspective, is a privilege."

Winston cares for inpatients at San Francisco General Hospital (SFGH) four months a year, both as a primary medicine attending and as an infectious diseases consultant. As SFGH's vice chief of inpatient medical services, she has improved patient care and educational opportunities for trainees. She also serves as SFGH's hospital epidemiologist, helping reduce hospital-associated infections such as Clostridium difficile.

In addition to her formal duties, residents and faculty stop by Winston's compact office each day to discuss challenging cases. "As a master clinician, she brings a confident clarity that systematically sorts through complex cases, discarding the chaff to identify and hold on to the kernels that represent the essence of the case," says Jeffrey Critchfield, chief of the Division of Hospital Medicine at SFGH.

Winston also lectures widely throughout the Bay Area, and greatly enjoys helping trainees learn and apply new knowledge. She recalls her own formative experience as a second-year resident, when Henry "Chip" Chambers, MD, former chief of the Division of Infectious Diseases at SFGH, asked her to serve as the infectious diseases point person over the weekend. "Chip said, 'Don't worry, you can call me,'" says Winston, recalling her apprehension. "I paged Chip multiple times - he was incredibly patient and talked me through all the stuff. At the end of the weekend, I felt that the next time I would be able to do it with a little more confidence and grace."

Chambers became one of her many mentors. "Chip is a minimalist," says Winston. "One of the wisest things he taught me is, 'Do no harm.' He's definitely pushed me to think about the consequences of our recommendations and potential side effects." This has become especially important in an era of increasing resistance to antibiotics. "The [antibiotic] pipeline is not as robust as the organisms are creative and resilient, and when you run out of drugs to give a patient, it's very sobering," she says.

She is honored to join many of her mentors as a master clinician. "They're all very caring and invested in the patients, they are collaborative, and they are all extremely intellectually curious," says Winston. "They want to keep getting better. The most important thing is that it's a journey."

Winston is married to Phillip Kennedy, MD, a hospitalist at California Pacific Medical Center. Together they have 12-year-old twin girls, Clara and Allison, and enjoy taking family hiking trips.

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