Master Clinicians: Recognizing Clinical Excellence

reprinted from Issue 19, Fall 2014 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.

Dr. Bradley Lewis

Dr. Paul L. Nadler

Dr. Bradley Sharpe

Dr. Dolores Shoback

From History to Medicine

Dr. Bradley Lewis
Health Sciences Clinical Professor
Director, Hematology, San Francisco General Hospital

Bradley Lewis, MD, director of hematology at San Francisco General Hospital (SFGH), has always gravitated towards complex challenges. During college, he joined Students for a Democratic Society and the Weather Underground, speaking to campus groups about the Vietnam War. "People didn't know how to think about political and social issues in a coherent way, so I went back to school in history," said Lewis. "I wanted to look at how people solve problems that don't have solutions."

After graduating from the Massachusetts Institute of Technology with degrees in biochemistry and history, he pursued a PhD in history. An advisor recommended going to medical school to help him land a tenure-track job in history. He took her advice, but fell in love with medicine, abandoned history, and became a hematologist.

In 1984, he began his practice at Alta Bates Hospital in Berkeley, just as the AIDS epidemic was devastating the hemophilia community. "I wasn't happy to see my patients get sick, but I liked the emotional intensity, and needing to think your way through to a solution in an area where the answers weren't clear," said Lewis. He established the adult hemophilia program at Alta Bates, directing it for over 20 years, and also co-founded the East Bay AIDS Center.

He also spent one month every year moonlighting on the hematology service at SFGH, which provided an outlet for his passion for teaching and a window onto groundbreaking AIDS discoveries. In 2006, he was recruited to the UCSF faculty full-time. Lewis uses the same skills he honed as a historian to explain complex hematology issues. "Information can be passed on more efficiently by a book, but I can make it memorable with stories," he says. "Also, you need to look seriously at the edges of the picture – if things don't quite fit, you need to have a good reason for why, or keep puzzling it out until it works."

"Brad has a way of explaining complicated concepts precisely and memorably, without oversimplifying them, tailoring his explanations to his target audience," says Beth Harleman, MD, associate program director of the UCSF Internal Medicine Residency Program.

Lewis loves caring for seriously ill patients, but watching so many of them die has been challenging. "A mentor told me, 'One of the blessings of being in this business is that you get to feel,'" he says. "A hundred years ago, the clergy would mediate between life and death. Physicians have taken over that job to a large extent, guiding people across the passage between the known and the unknown."

Although he serves as an attending physician at least 10 months annually, Lewis balances intense clinical work with other passions, including flying planes and skiing. He has two grown children, Jesse and Rebecca, and is married to Lorinda Coombs, RN, MSN, ARNP, a former nurse practitioner at SFGH who is currently a PhD candidate at UCSF. Together they have a 5-year-old daughter, Eleanor.

Caring for the Whole Patient

Dr. Paul L. Nadler
Health Sciences Clinical Professor
Medical Director, UCSF Screening and Acute Care Clinic

Sprained wrists, stomach pain, skin infections – as medical director of the UCSF Screening and Acute Care Clinic, Paul L. Nadler, MD, sees all these conditions and more. In addition to the fast pace and variety, he enjoys working with his hands. "Building a splint is very tactile and creative, almost like sculpting," says Nadler. "I also get to chat with patients about things that might not come up in a formal medical interview."

For example, a patient might mention that he injured his ankle after a Saturday night pub crawl. "I might find out about an untreated condition such as alcohol abuse that could benefit from counseling," says Nadler. "It can be a teachable moment, when they are open to considering issues that might have led to their injury."

Many of the clinic's patients are young people who do not regularly see a doctor. The ailments that bring them in can actually provide a golden opportunity. "My goal is to expand the definition of acute care to also address underlying health issues," says Nadler. He and Ralph Gonzales, MD, MSPH, chief innovation officer for the UCSF Health System, developed a tablet- based questionnaire that patients can complete in the waiting room to identify risk factors for conditions such as HIV or hepatitis B. "It allows us to provide more comprehensive care in a nonjudgmental, efficient way, yet doesn't distract us from the issue at hand," says Nadler.

He also created a system that allows patients to book same-day appointments online or over the telephone. "Before, patients didn't know if they'd be seen in 30 minutes or three hours, and were terrified that if they went to the bathroom, they'd miss their name being called," he said. "When patients feel their time is being respected, they come in happier."

Early in his own career, Nadler found he was underprepared to treat many acute care issues, such as orthopedic injuries and eye conditions. "It's not uncommon for somebody to present to us with significant problems that can be overlooked if you don't ask specific questions or perform specific exam techniques," he says. "We teach residents so they leave with a skill set to effectively take care of their patients."

"Paul is truly revered for his combination of clinical expertise, kindness and generosity," says Fran Dreier, FNP, MHS, who has worked with Nadler for more than a decade. "His answers always stimulate reflection, while respecting the autonomy of the questioner."

Nadler often puts in 12-hour days, including many Saturdays, and sees about 160 patients a week. Yet his enthusiasm continues to energize him. "If a person or their family member is ill, almost nothing else seems to matter," he says. "I'm fortunate to have the training and experience that, in many cases, allow me to make a difference. That's a very privileged position."

In his free time, Nadler enjoys sailing, running and spending time with his wife, Helen, and their young daughter, Elizabeth.

The Power of Teaching

Dr. Bradley Sharpe
Professor of Clinical Medicine Associate Division Chief, Division of Hospital Medicine
Associate Program Director, UCSF Internal Medicine Residency Program

"It's an honor to have a window into a person's life when they're at their most vulnerable," says Bradley Sharpe, MD. As associate chief of the Division of Hospital Medicine, he helps oversee care of about 100 hospitalized patients a day at UCSF Medical Center. "The intensity of the interaction with patients is profound," he says. "I try to make a connection and help them feel at ease."

He builds rapport by sitting down to talk with patients and families, using their words and language when possible. "If a patient says, 'I'm having heart trouble,' I say, 'Let's talk about your heart trouble,' rather than 'You have congestive heart failure,'" says Sharpe. "Also, studies have shown that clinicians often talk way too much. I try to elicit patients' goals and what they're worried about, and get them to do most of the talking."

Sharpe is passionate about medical education. He serves as associate program director for the UCSF Internal Medicine Residency Program, and teaches faculty in different departments to be more effective teachers. "People may know everything about a disease, but how do you teach so it changes the way trainees take care of patients?" he asks. Sharpe strives to establish a positive learning climate and provide specific feedback to learners. "Instead of saying, 'Great job with that patient,' I'll say, 'You clearly explained the plan without medical jargon – that was great,'" he says. "Rather than saying, 'You were rude to that patient,' I'll say, 'You got up to leave while the patient was still talking,' which focuses on specific behaviors."

Sharpe loves teaching about his "favorite disease," community-acquired pneumonia. "I like the physical exam, the evidence base, and knowing that patients usually get better," he says. Sharpe also coaches trainees on improving oral case presentations – in which they outline a patient's history, physical exam, lab results and their own clinical reasoning – encouraging them to focus on what listeners need to hear and to practice presentations out loud. On a national level, Sharpe helps organize the Academic Hospitalist Academy, a boot camp course for junior academic hospitalists. He is also a board member of the Society of Hospital Medicine, the national organization for hospitalists.

"Brad is among the very best clinical teachers in our department," says Robert M. Wachter, MD, chief of the Division of Hospital Medicine and Lynne and Marc Benioff Endowed Chair in Hospital Medicine. "He is also the kind of person that anyone would love to have as his or her doctor – whether the problem required 'Dr. House'-like brilliance or just sitting at the bedside of a dying patient, quietly listening."

"My proudest moments are when I see someone teaching what I taught them," says Sharpe. "If I teach 10 residents the appropriate antibiotics for pneumonia, and then each of them teaches eight interns, that's the exponential power of teaching." He is married to Margaret Fang, MD, MPH, also a UCSF hospitalist. Together they have two young daughters, Alexandra and Ariadne.

An Exquisite Balance

Dr. Dolores Shoback
Professor of Medicine in Residence, San Francisco Veterans Affairs Medical Center
Associate Director, UCSF Diabetes/Endocrinology/ Metabolism Training Program

Endocrinologist Dolores Shoback, MD, has discovered many secrets of the parathyroid glands, four pea-sized organs in the neck. Small but mighty, they regulate the bloodstream's calcium balance by releasing parathyroid hormone (PTH), which stimulates bones to release calcium and kidneys to hoard it rather than releasing it into the urine.

Besides forming bones, calcium plays a critical role in helping muscles contract, nerve cells fire and blood to clot. Calcium is plentiful in seawater, but not on land – so when our ancient forebears crawled out of the ocean, they evolved ways to tightly regulate this essential mineral. "This is definitely a system where things need to be just right," says Shoback. If PTH levels are too high, people develop osteoporosis and kidney stones; too low, causes numbness, cramps and other serious problems.

Shoback, recruited to the San Francisco Veterans Affairs Medical Center (SFVAMC) in 1983, led studies in development of calcimimetics – drugs that trick the parathyroid glands into thinking that bloodstream calcium levels are high, thereby inhibiting PTH release. This research contributed to approval of the first calcimimetic to treat hyperparathyroidism – overly active parathyroid glands – and parathyroid cancer. She also made key discoveries about calcium-sensing receptors, which are found not only in the parathyroid glands, but also in almost every cell in the body. Shoback helped define how such receptors in cartilage interact with various hormones to regulate bone growth. "These cells are scoping out what's in the environment, because tissues have to have enough [calcium] to make a structurally competent bone," says Shoback.

She brings the same scientific rigor to caring for patients, many of whom have diabetes or osteoporosis. "Medicine is an art, but there is a lot of science involved," Shoback says. "It is a great advantage to be able to interpret new clinical research when making a recommendation to a patient." Says endocrinologist Anne Schafer, MD, "Dr. Shoback is constantly attentive to patients' needs, exceedingly thorough, and immensely compassionate."

One of Shoback's strongest role models was Johns Hopkins clinician Philip Tumulty, MD. "What was most impressive was how he dealt with situations where he couldn't come up with a diagnosis," she says. "He never abandoned his patients. He maintained a healing relationship. Many times with diabetes, the disease progresses. You may not be able to reverse deterioration of sight or kidney function, but the patient actually needs you even more at that point. You continue to be their doctor, and to support them and their family."

An esteemed educator and consultant, Shoback is internationally respected, and recently chaired annual meetings of the Endocrine Society and the American Society for Bone and Mineral Research. She is married to John Imboden, MD, chief of the Division of Rheumatology at San Francisco General Hospital and himself a Department of Medicine Master Clinician. They have two grown children, Tom and Elizabeth, and enjoy opera and international travel.

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