UCSF Department of Medicine: 2017 Annual Report by UCSF Department of Medicine

Inventing the Future of Medicine 2017 Annual Report

NIH FUNDING RANKING:

Highlights INTERNAL MEDICINE

The UCSF Department of Medicine was the top recipient of funding from the National Institutes of Health (NIH) of any academic department in the United States. During the 2016-2017 fiscal year, the department – with $200,256,253 in funding – was the first ever to receive more than $200 million from the NIH in a single year.

RESIDENCY RANKING:

MEDICAL CENTER RANKING:

In its listing of Best Grad Schools, U.S. News & World Report ranked UCSF’s Department of Medicine as the top graduate program for internal medicine in the nation. U.S. News & World Report also ranked UCSF Medical Center as the 5th best hospital in the nation and the best in the western U.S. – with six specialties from the Department of Medicine ranking in the top 10 in the nation: nephrology (5th), pulmonology (6th), rheumatology (7th), diabetes and endocrinology (7th), oncology (10th), and geriatrics (10th). In addition, gastroenterology and cardiology were both ranked in the top 25.

2017 Annual Report

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Contents

Message from the Chair

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A Data-Driven Detective Story

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A Conversation with Julia Adler-Milstein, Director of the UCSF Center for Clinical Informatics and Improvement Research

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Reimagining Outpatient Care

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Doubling Down on Diversity

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Unique Collaboration

This was a year of tremendous accomplishments by the faculty, trainees, and staff of the UCSF Department of Medicine.

Powers Groundbreaking Translational Research

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Highlights from the Divisions

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Reintegrating Subspecialty Medicine and Basic Science into Medical Education

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Basic Research: Support for Risk-Taking Opens the Doors to Discovery

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Research Funding and Publications

ome of this is captured in a series of statistics and rankings. In its list of Best Grad Schools, U.S. News & World Report ranked our department as the best internal medicine department in the United States. Once again, our academic department led the nation in National Institutes of Health (NIH) grants, becoming the first department to pass $200 million in such grants in a single year. UCSF Medical Center was ranked 5th in the nation by U.S. News & World Report, making it the top hospital in the country west of the Mayo Clinic; six specialties from our department were among the top 10 in the country. But the numbers don’t capture the spirit and soul of our magnificent department. In this message and in the rest of this annual report, I’ll provide a glimpse of how our faculty, trainees, and staff are reinventing the way we ask and answer the hardest questions in health care, teach our trainees, and care for our patients. As a world leader, it’s what we’re here to do.

Clinical Care

Several years ago, I was speaking to a group of UCSF medical students. I thought they should appreciate how much the world of medicine has changed since I was in their shoes. “All of you are entering a profession utterly different from the one I entered 30 years ago,” I said gravely. “You’ll be under relentless pressure to figure out how to deliver the highest-quality, safest, most satisfying care… at the lowest possible cost.” One student raised his hand. “What exactly were you trying to do?” he said. I often think about that student’s question. There is no doubt that the transition from volume to value is chock-full of challenges, such as measurement burden, the promotion of check-box medicine, and the emerging evidence that today’s quality metrics disadvantage academic health centers and institutions that treat low-income populations. Nevertheless, it’s hard to argue that a shift from our traditional volume-based system to one that promotes high-value care is the wrong direction. Our department has not only accepted this challenge, but is also determined to lead. In the past 10 years, we’ve seen major transformations at all of our clinical sites. As organizing principles, we’ve embraced “lean” methodology and the concept of a learning health care system to guide continuous improvement. We’ve developed and nurtured clinical partnerships between UCSF Health and a variety of nonacademic providers; we’ve forged stronger ties to community clinics at Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) through the San Francisco Health Network; and our faculty and trainees at the San Francisco VA Medical Center have built and staffed a number of new clinics, as well as telemedicine facilities, to reach out to our veterans. We’ve implemented – and often pioneered – innovative ways of organizing care, ranging from new apps for managing hypertension to teambased care and e-consults. I want our department to remain at the forefront of innovative new models of care delivery, and, as you’ll see in these pages, we’re doing just that.

Research

In a department whose faculty and trainees last year published more than 3,300 articles and were awarded 632 peer-reviewed grants and fellowships, it’s impossible to capture the breadth of our research activities in a few pages. But we hope a few examples will give you a flavor of the work. You’ll read about novel uses of electronic health record data to sleuth out the cause of infections, a unique partnership to prevent the ravages of chronic kidney disease, and major advances in gene editing and our understanding of immune biology. Moreover, as our campus at Mission Bay has grown, it has evolved into a robust research hub, surrounded by a number of pharmaceutical, device, and technology companies that seek partnerships with our world-class investigators. While our multiple campuses pose a challenge in terms of communicating with colleagues and nurturing communities (San Francisco’s streets seem to be filled with ridesharing cars and UCSF shuttles), our growth has also afforded us unprecedented opportunities. New research facilities are also slated to come online in the next few years at Parnassus, the VA, and ZSFG.

Education

Our training programs have long been recognized as among the nation’s best, and we remain exceptionally proud of our trainees – many of whom become leaders at UCSF and around the world. In this report, we talk about new efforts to increase our residents’ exposure to subspecialty medicine and fundamental science, including a new molecular medicine consultation service that is supported by a major gift from Mark Zuckerberg and Priscilla Chan (the latter a UCSF School of Medicine graduate). In addition, many of our faculty serve as coaches for groups of our medical students participating in the innovative Bridges Curriculum, which embeds students in clinical practices to learn not only clinical medicine, but also teamwork and quality improvement.

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The Chair’s Council, composed of the associate and vice chairs of the department, assists me in leading our 3,000 employees (including 750 paid faculty), with a yearly budget of half a billion dollars. ROBERT M. WACHTER, MD

Philanthropy

UCSF continues to be an international powerhouse in receiving philanthropic donations, and our department plays a central role in these efforts. Last year, UCSF ranked 5th in the nation among institutions of higher learning in philanthropic dollars received. This might not seem all that remarkable until one realizes that our school is a health sciences-only institution, with no business, law, or undergraduate school – and no sports teams!

D I V I S I O N D O N AT I O N T O TA L S

Occupational and Environmental Medicine

$ 135,500

Some of this success is due, no doubt, to the remarkable economic engine that is Silicon Valley, and to the generosity of those who have been fortunate in their business pursuits. But much of UCSF’s success is also owed to the remarkable work being done by our people – inspiring work that prompts donors to trust that their gifts to UCSF and our department – which in fiscal year 2017 totaled more than $32 million – can lead to breathtaking discoveries and models of care.

Pulmonary, Critical Care, Allergy and Sleep Medicine

$ 402,160

Cardiology $ 14,851,238 Center for AIDS Prevention Studies $ 191,198 Gastroenterology $ 259,510 General Internal Medicine

Geriatrics $ 1,964,011 Hematology and Oncology Infectious Diseases

$ 7,803,087 $ 232,335

Nephrology $ 199,347

Rheumatology $ 3,351,281 Other $ 675,102

$ 32,583,087 N O TA B L E B E Q U E S T S Cardiology Donald Wyler

$ 920,000

Geriatrics Estate of Joseph Padula

$ 105,000

Rheumatology Estate of Jean and Ephraim Engleman

$ 2,518,318

$ 2,535,000

Our People

Leadership

It is now well appreciated that rates of burnout among U.S. physicians are going up, driven by increasing economic pressures and the burdens associated with our bumpy path to digital medicine. With NIH funding relatively flat, our researchers – like those everywhere – are also struggling to achieve a stable funding path.

I am privileged to be surrounded by an exceptional group of leaders, all of whom share my commitment to making our department the most innovative, exciting department of medicine in the country, and the best place to work. The Chair’s Council, composed of the associate and vice chairs of the department, assists me in leading our 3,000 employees (including 750 paid faculty), with a yearly budget of half a billion dollars. In addition, our 35 division chiefs, national leaders in their own right, manage their specialty divisions with tremendous skill and passion, and with the able assistance of our division managers.

UCSF and our department are aggressively addressing faculty and staff burnout with programs that range from advanced teleconferencing to faculty onboarding programs to robust leadership training. I am pleased that we’ve seen impressive improvements in satisfaction, for both faculty and staff, in the past few years, although there is much more to do. In addition to improving the work climate for all of our people, we are making special efforts to diversify our workforce. I am particularly proud of our internal medicine residency program, which last year nearly doubled its percentage of interns from groups under-represented in medicine. As you’ll read in this report, we have made major investments in people and programs to improve diversity and to create a more positive climate for all of our people. Those efforts are paying off.

This is a time of considerable challenges in health care generally and academic medicine in particular, but I’m proud to say that our department continues to experience remarkable successes. I hope you enjoy the stories in this report, which highlight just a few of our extraordinary people and programs. I’d be pleased to speak with you about any aspect of our work.

CHAIR’S COUNCIL A B OVE, FR OM L EFT:

David Erle, MD Associate Chair, Biomedical Research Beth Harleman, MD Associate Chair, Faculty Experience Michelle Mourad, MD Vice Chair, Clinical Affairs and Value Andrew Gross, MD Associate Chair, Ambulatory Care and Population Health Paul Volberding, MD Associate Chair, Global Health Patricia Cornett, MD Associate Chair, Education Robert Wachter, MD Chair, Department of Medicine

Robert M. Wachter, MD Professor and Chair, Department of Medicine Holly Smith Distinguished Professor in Science and Medicine Lynne and Marc Benioff Endowed Chair in Hospital Medicine

Maria Novelero, MA, MPA Associate Chair, Administration Kenneth McQuaid, MD Vice Chair and Chief of Medical Service, SFVAHCS Neil Powe, MD, MPH, MBA Vice Chair and Chief of Medical Service, ZSFG Diane Havlir, MD Associate Chair, Clinical Research Michael Chen Associate Chair, Finance

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Despite its considerable promise to improve care, far too many clinicians still view the electronic health record (EHR) as a clunky intruder, one that is depersonalizing health care and increasing demands without improving outcomes in any discernible way. “Digitizing health care with the EHR was a critical first step in beginning the transformation from the error-prone, inefficient world of handwritten paper records toward an efficient, high-quality, reliable system.… And we are now coming out of the post-implementation gloom and beginning to see creative, impactful uses of the EHR data, helping us improve quality and efficiency across the organization,” says cardiologist Michael Blum, MD, director of the UCSF Center for Digital Health Innovation and associate vice chancellor of informatics at UCSF.

Leadership in the Era of Digital Innovation

A Data-Driven Detective Story Sara Murray’s project to reduce a dangerous hospitalacquired infection is one example of the kind of new thinking that will be required for digital medicine to achieve its promise of transforming care.

Uncovering the Riskiest Locales for C. difficile Transmission

Like many medical centers around the country, UCSF Health is determined to reduce the incidence of Clostridium difficile infection (CDI), one of the most serious, expensive, and potentially avoidable consequences of hospitalization. Yet because the spores that cause CDI are notoriously difficult to kill using traditional cleaning methods, reducing its incidence remains a challenge.

Hospitalist Sara Murray, MD, MAS – an assistant professor of medicine and the medical director of clinical informatics for UCSF Health – and her colleagues on the health informatics team believed that by extracting and analyzing data already present in the EHR, they could identify areas of the hospital that are particularly risky for CDI transmission. While most clinicians under-

stand that transmission can be accounted for, in part, by contact with surfaces contaminated with CDI, it is difficult to know where that transmission is occurring. Traditional approaches focused on the patient’s hospital room, looking for patterns of outbreaks on a given ward or near the room of an infected patient. Murray and her colleagues decided to use time stamp and location data collected (but rarely analyzed) in the EHRs of all hospitalized adults between 2013 and 2015 – 86,648 adult hospitalizations – to identify all the places each individual patient visited and when. When looked at through the lens of an individual patient’s journey around the hospital, the numbers were staggering: There were 434,745 patient location changes. “Places visited by a patient with CDI were considered ‘potentially contaminated’ for the following 24 hours,” explains Murray. The team then tracked patients who did not yet have the disease but had visited potentially

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contaminated spaces, and compared them with similar patients who had visited the area when it was not considered contaminated. Following that, the team identified patients who tested positive for CDI within the next 60 days. The result? Even after adjusting for confounders, a trip through the computed tomography (CT) scanner in the Emergency Department seemed to explain a large number of CDI infections. When the team brought this “hot spot” data to the attention of the hospital’s infection control department, leadership immediately instituted new cleaning protocols. The research team will follow up with a repeat analysis in a year to see if the changes have made a difference, but there is no doubt that this electronic sleuthing had provided an answer. The study appeared in the October 2017 issue of JAMA Internal Medicine.

Proof-of-Concept Study Opens Possibilities

“I’ve been thinking for a long time how cool it can be to use detailed EHR data to improve patient outcomes,” says Murray. “The CDI study was proof of concept.” Discussions are underway about using similar methods to reduce central-line infections. “There are so many time- and resourceconsuming studies we do now that can be done more efficiently and powerfully by leveraging EHR data,” says Murray. But such work is in its relative infancy and will require some system changes. EHRs are not designed for bulk retrieval of clinical data across patients, so they require a lot of detail-oriented work to design the necessary algorithms, while paying attention to clinical definitions and data validation. To be successful in this work, “You have to understand both the clinical medicine and the data architecture to know where errors

in data extraction can occur,” says Murray. Even when the technological problems are overcome, there’s the issue of convincing physicians that the computers have generated valid findings. “Sara’s work is an excellent example of the lifesaving data analytics work that we could never have done without going through the transition to the EHR,” says Blum. “We are just starting to scratch the surface of what we can do for our patients now that we are getting access to the data and employing the tools that have been available to other industries for years.”

Hospital Wards Procedural and Diagnostic Areas Emergency Department CT Scanner

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Leadership in the Era of Digital Innovation

A Conversation with Julia Adler-Milstein, Director of the UCSF Center for Clinical Informatics and Improvement Research Julia Adler-Milstein, PhD, directs the newly formed UCSF Center for Clinical Informatics and Improvement Research (CLIIR), the mission of which is to discover how to leverage information technology (IT) systems and data to improve health system performance at scale. Adler-Milstein, who was recruited to UCSF from the University of Michigan in 2017, is widely recognized as the nation’s top researcher in health IT policy, with a specific focus on electronic health records (EHRs) and interoperability.

What are your initial priorities as you

We will start with a strategic planning “ process. I’m excited to engage a diverse

assume the job?

group of UCSFers to determine our priorities. However, there is a set of topics that are likely candidates. One focus will be the frontline provider experience of using EHRs and other related technologies. People often talk of the “burden” on providers, but we need to understand more deeply what we mean when we use that term. Is it just extra hours in the day? Is it different types of cognitive burden? Burden is not a concept we’ve fully articulated or figured out how to measure empirically. It’s hard to improve or know if we’re making progress if we don’t know what to measure. We also want to explore the complex balancing act between optimal provider use of technology on the front lines of care, and the need for providers to respond to external EHR documentation requirements to support quality measurement, payment, et cetera. A key reason why EHRs are so valuable is that they can serve many purposes, but today that’s translating to a disproportionate share of work on frontline providers.

”

How do these questions differ

A strong body of research has examined “ physician satisfaction with electronic health

from what’s been

records, and we have a good understanding of the negative implications of their frustration. A few studies have also isolated specific relationships – how much time physicians spend documenting, how many pop-ups they receive – but we haven’t fully connected how these inputs interact to impact downstream outcomes. If I could come to Russ Cucina [professor of Medicine and chief health information officer for the UCSF Health System] with a clear understanding of the connections, then we could improve more rapidly. studied to date?

”

How do you envision the CLIIR team

One of the reasons I took on this challenge “ is because everyone I spoke to saw CLIIR

working with existing

as filling a gap in what exists at UCSF – specifically, a research center devoted to rigorously studying how health IT is working in real clinical settings to impact outcomes we care about. More broadly, if we are to reach our goal of becoming a nationally recognized and, ideally, internationally recognized research center examining how we use technology to improve health system performance, we have to work very closely and synergistically with many other groups at UCSF – and we’re excited about that. There are some obvious groups, particularly the Institute for Computational Health Sciences and the Center for Digital Health Innovation. But there are also less obvious ones. For example, in talking with Ralph Gonzales [professor of Medicine, associate dean for Clinical Innovation, and chief innovation officer for UCSF Health], many of the projects within his Clinical Innovation Center focus on problems that have nothing to do with technology. But even if the problem doesn’t relate to IT, the solution almost always does – or is in some way impacted by the electronic health record. groups at UCSF?

”

How will CLIIR

One of the reasons I took on this challenge is because everyone I spoke to saw CLIIR as filling a gap in what exists at UCSF – specifically, a research center devoted to rigorously studying how health IT is working in real clinical settings to impact outcomes we care about.

operate?

challenge is “to My bring together a group of faculty members from within and outside UCSF who care about technology and studying its impact on outcomes and who want to work in a highly collaborative, interdisciplinary environment. At the most fundamental level, that’s the litmus test for who we are seeking at CLIIR. We also want to attract people who are excited to think about applied health informatics research in new ways that account for how technology interacts with humans and all their complexity. In particular, I hope to find colleagues who want to examine the interactions between clinicians and computers in a more sophisticated and nuanced way than we’ve done in the past. There are underused sources of data that offer a lot more granularity into what was done, as well as where and when. Such data can be used to infer clinical decision-making processes and the effect of technology

JULIA ADLERMILSTEIN, PHD

on those processes. For example: When physicians are busier and have more open charts, how does that impact decision making and potentially degrade the quality of decision making? To support this research, I plan to build a unique data warehouse that includes metadata from the electronic health record, and which captures who is doing what, when, and where every second of every day. It’s a gold mine, but one that needs investment to make research-friendly.

”

How will you pursue both short- and

There is a set of issues that we have been “ wrestling with for some time. They don’t

long-term goals

have easy solutions, and they’re likely to get worse as health care continues to get more complex. These are the sweet-spot issues for CLIIR. I tend to be very practical; if we have a persistent problem, it is unlikely that a silver-bullet solution lies just around the corner. Instead, we need to understand the sociotechnical complexity and assess solutions that are designed to accommodate that complexity. Right now, provider burden and interoperability are topics that fit the bill. Making progress on these issues requires new approaches to fundamental challenges – such as the question of who EHRs are really designed to serve. We’ve never clearly specified who the master is. It’s clear who my iPhone is here to serve, but for EHRs, it is a lot of constituents with conflicting priorities. We need to tackle this head-on and figure out how to address those conflicts. It’s an exciting challenge, but we also have to be realistic. CLIIR ultimately must support itself, and being a successful center director means successfully securing funding streams. In this environment, that requires creative diversification – grants, donors, and forging partnerships with technology companies that value research. I hope to inspire potential supporters with our fresh approaches to tackling substantive, complex, real-world problems standing in the way of health care’s digital revolution. simultaneously?

”

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Reimagining Outpatient Care It is now widely appreciated that the health care system is moving from volume to value. In the outpatient world, this means a much greater focus on population health, prevention, and the use of technology to manage patients with chronic conditions and comorbidities across settings. While few argue with the need for such reforms, the multiple imperatives can lead to burnout, which undermines all of reform’s best intentions. That’s why, over the last year or two, the Department of Medicine’s outpatient efforts have focused on improving both the patient and the provider experience. In UCSF’s different health systems with very different challenges and patient populations, outpatient teams often use “lean” methodology to rigorously examine existing practices, identify new skill sets, and design new processes. The goal is to improve team-based care, advance patient management techniques, expand access to care, and communicate more effectively with patients and among clinical teams – without overburdening providers.

Cardiologist Rajni Rao, MD (center) and Rose Pavlakos, PharmD, RPh (left) with a patient

Patients became super engaged in their own care. Lifestyle changes were much more transparent to them, and they owned their number so much that we could often reduce their reliance on medications. RAJNI RAO, MD

Advanced Patient Management

As health systems seek better ways to manage chronic conditions across entire patient populations, increasingly sophisticated mobile apps offer simple, affordable ways that, in theory, help patients and clinicians better measure and manage key clinical indicators. “But the apps are only useful if integrated into the care delivery process and the electronic health record – with someone inside of the patient’s health care team interacting with that information,” says Nat Gleason, MD, medical director for practice innovation at UCSF Health. Several groups in the department are taking that idea to heart, including the Division of Cardiology. Concerned that many patients were not reaching their prescribed blood pressure goals between quarterly appointments, cardiologist Rajni Rao, MD, and her team piloted the use of an app that made it easy for patients to take their blood pressure

twice a day and transmit that information electronically to the cardiology team. When measurements fell outside a physician-prescribed range, the team received an alert, and a pharmacist engaged the patient to titrate his or her medications. More than 80 percent of patients reached or exceeded their prescribed goal within two weeks. “Patients became super engaged in their own care,” says Rao. “Lifestyle changes were much more transparent to them, and they owned their number so much that we could often reduce their reliance on medications.” Rao’s team is also bringing team-based care and technology to its Cardiac Outpatient Recovery (COR) clinic. The clinic’s nurse practitioner (NP) meets patients in the hospital who are at high risk for readmission to prepare them for their follow-up appointment and address any barriers to getting there, such as transportation and social work needs. The NP also walks families through the use of an online portal and mobile health application that facilitate patients’ abilities to communicate with providers. Using these techniques, the clinic has significantly reduced the no-show rate for follow-up appointments and successfully connected the vast majority of its patients to primary care, outpatient cardiology, or cardiac rehabilitation programs, says Rao.

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Making Team-Based Care a Thriving Reality

Alice Chen, MD, MPH, is the chief medical officer for the San Francisco Health Network (SFHN), the city’s publicly funded health care delivery system. The system includes the Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG) and provides care to many of the city’s underserved communities. She and her colleagues have long understood that thoughtfully deploying clinical teams and helping all team members – regardless of discipline or degree – work to the top of their licenses can benefit patients and providers alike. With that in mind, the SFHN has invested in its primary care workforce in multiple ways. One important effort has been the early integration of behavioral health into primary care. “Every primary care clinic has a behavioral health team, including a licensed clinician – a licensed clinical social worker [LCSW] or psychologist – for short-term counseling and a behavioral assistant, whose responsibility is to connect patients with community resources,” says Chen. In 2017, the SFHN extended its team-based thinking by forming a partnership with Health Leads, a national nonprofit organization that connects low-income patients with basic community resources, in part by providing access to a centralized database. For care managers, up-to-date information can be accessed with the click of a mouse, along with ratings that indicate which resources best meet patient needs. “If we are going to continue to move to a model that is more proactive and focused on population health, we have to make sure patients have the means to stay healthy and that our providers have an easy way to connect patients to the best resources,” says Chen. Similarly, at the department’s Mount Zion primary care clinics, the Division of General Internal Medicine (DGIM) has teamed with a psychiatrist who serves as a consultant to help primary care physicians screen for and manage depression and anxiety, and who sees patients directly to address short-term mental health needs. “The expectation that primary care clinicians will manage mental health needs has risen dramatically, so having integrated mental and behavioral health in primary care improves clinical outcomes, patient satisfaction, and everyone’s work-life balance,” says Mitchell Feldman, MD, MPhil, chief of the DGIM. The division has also added an LCSW and patient navigators to help connect patients to specialty mental health services in the community, provided physicians with more decision support in the EHR, and rolled out universal screening for depression at least once a year.

Alice Chen, MD, MPH

Mental health is only one of many pressing needs that demand reformulated clinical teams. The SFHN’s Positive Health Clinic has created a new program – Golden Compass – that integrates a geriatrician into the clinical team to address the complex needs of older patients with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS). (It’s worth taking a moment to reflect on the staggering progress represented by a geriatric HIV practice.) “The program is attuned to some of the issues that come into play in the context of this specific disease process and population,” says Chen. Yet effective team-based care must also go beyond integrating clinical and social services, says Lukejohn Day, MD, director of clinical gastroenterology and the associate chief medical officer for specialty care and diagnostics at ZSFG. Day says that positively engaging staff – by setting goals and acknowledging successes in things like performance improvement huddles, whiteboard notes, and operational dashboards that gather data and track progress – is essential. “It’s been incredibly powerful, and it only takes 10 to 15 minutes a day,” he says. Rao agrees. The UCSF Health Division of Cardiology provides leadership opportunities for all staff and helps them identify and pursue realistic goals for things such as reducing the number of patients in line. “The staff is happier, and it has a wonderful effect on patients,” says Rao, the ambulatory service chief for the division. “We recently reached a new milestone in patient satisfaction – three months straight where we had 100 percent of patients give us 10 out of 10 for ‘likely to refer.’”

If we are going to continue to move to a model that is more proactive and focused on population health, we have to make sure patients have the means to stay healthy and that our providers have an easy way to connect patients to the best resources. ALICE CHEN, MD, MPH

Day adds that e-consults can further expand the team concept. ZSFG was a national pioneer in using the concept, which enables a generalist to ask a question of a specialist without requiring a patient to travel for an in-person evaluation. UCSF Health created its own variation

on the ZSFG concept when it launched e-consults in 2012. Today, all Department of Medicine specialties – along with neurology, psychiatry, and other specialties – offer the service. “The right e-consult question enables a specialist to weigh in based on the primary care physician’s narrative and data from the shared medical record,” says Gleason. “Here, our expectation is a three-day turnaround, which is timelier than usual care.” Adoption has been strong. For example, UCSF primary care patients now receive 21 percent, 22 percent, 40 percent, and 47 percent of their endocrinology, nephrology, hematology, and infectious disease care, respectively, via e-consult. “Patients like it, and it makes our cardiologists happy, too, because we have more in-person slots for our complex patients and can really practice our craft,” says Rao.

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Expanding Access to Care

Innovations don’t matter unless patients can access them, so a few years ago Day and his team began automating data collection for patient wait time and other measures across all 67 specialty clinics at ZSFG. One key goal was to reduce to less than 21 days the average length of time between the day a patient requests an appointment and the third available appointment – a commonly used measure of appointment availability – for a new patient physical, routine exam, or return exam. When Day and his team found that the clinics achieved this goal only 15 percent of the time, they instituted a number of improvement efforts, including: Group education,

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Specialty clinics at ZSFG are now achieving the 21-day goal more than 90 percent of the time. UCSF Health has also expanded adoption of its video visits. “We’re simplifying and standardizing workflows to support faculty and staff as fast as we can. It should be efficient and familiar for the physician,” says Gleason. “We know that the patient experience – saving time, travel cost, child care, missed work – is extraordinary.”

More Effective, Efficient Communication

Improving communication – whether doctor-patient, among physicians, or among all clinical staff – is another piece of adapting successfully to change. This year, department experts began providing daylong communication training to all of its primary care physicians, using primary care case studies to adapt proven inpatient communication techniques to the outpatient setting. Outpatient physicians have also begun to use the EHR’s messaging capabilities to achieve clinical goals for things like smoking reduction, with the combined benefits of a better patient response, higher levels of patient satisfaction, and more positive quality metrics. In addition, at most primary care clinics, morning huddles draw on clinical dashboards that enable teams to quickly view the day’s priorities for each patient, discuss and clarify individual roles, and, in turn, optimize how each clinician’s skill set is used.

The UCSF Department of Medicine practices at UCSF Health facilities at Parnassus, Mount Zion, and Mission Bay; the San Francisco Veterans Affairs Health Care System; the Priscilla Chan and Mark Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG); community clinics affiliated with the San Francisco Health Network; and satellite clinics throughout Northern California.

Addressing Burnout

Even as the department continues to pursue innovation, it has not lost sight of how change fatigue can lead to burnout for physicians transitioning from traditional ways of delivering care. “Asynchronous care has had a big effect,” says Coleen Kivlahan, MD, MSPH, UCSF Health’s executive medical director of Primary Care Services. “After a full-day clinic, physicians still have to finish patient notes and respond to patient emails. This can make it feel as though there is no end to our day.” In response, UCSF Health is implementing a number of interventions, including on-site or off-site scribes who help create physician notes, and piloting the use of Google Glass to directly enter examination findings into the EHR in real time, helping the patient and physician better understand each other. The system is considering new technologyenabled approaches, including emerging voice recognition programs, to further improve the efficiency of the process.

Another source of burnout is the stress that results from measuring physician productivity merely by the number of clinic visits he or she conducts. UCSF has begun experimenting with new formulas that account for the complexity of the patient mix, as well as the balance between in-person and asynchronous care. “Over the long term and once they are fully in place, we believe these types of innovations will help address inefficiencies that contribute to burnout and, in turn, improve morale,” says Jon Rueter, MBA, division manager for General Internal Medicine. Day adds that to make that happen, it’s critically important to collect data and share progress with both leaders and frontline staff. “That keeps everyone involved in improving – in formulating ideas and solutions – which leads to better results.”

Day says that positively engaging staff – by setting goals and acknowledging successes in things like performance improvement huddles, whiteboard notes, and operational dashboards that gather data and track progress – is essential.

It’s been incredibly powerful, and it only takes 10 to 15 minutes a day. L U K E J O H N D AY, M D

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Doubling Down on Diversity

Justin Moore, EdD Beth Harleman, MD Sarah Schaeffer, MD, MPH Meshell Johnson, MD

Many things contribute to a more efficient, patientcentered health care system, but research clearly shows that one key element is a clinician community that understands the culture, language, expectations, and concerns of its patients. “In my experience, it’s absolutely true that diverse teams challenge all of us to come up with better solutions,” says Beth Harleman, MD, the department’s associate chair for faculty experience.

“I’m happy the numbers reflect our efforts, but numbers ebb and flow,” says hospitalist Sarah Schaeffer, MD, MPH, director of residency and fellowship diversity for the department. “I’m more interested in trends improving over time, and more pleased about some of the intangibles: the ways we talk about race, the commitment from leadership to listen and make changes, the ways we review applicants and the conversations around that. It’s the change in culture that sustains improvement.” Schaeffer – a Mexican American woman from El Paso, Texas – was an undergraduate at Boston University, went to medical school at NYU, and did her residency and chief residency at UCSF. “As I moved higher in education, the disparity between minorities and their providers became more apparent,” she says. “I saw the connections I was able to make with Spanish-speaking patients – it was part language, part cultural understanding – and spoke from my identities as both a Mexican American and an LGBT person to promote diversity in my medical school.” As that happened, she began to recognize that her cultural identities were valuable attributes – as important as research prowess or the ability to teach – that she brings to the table as a medical professional. “I wanted to see that recognized,” she says. Such recognition is happening at UCSF, but barriers remain – and the department is actively addressing them.

Despite this understanding, many top-notch academic medical centers are still not where they want to be in attracting residency, fellowship, and faculty applicants that mirror their patient population. UCSF and its Department of Medicine are making a concerted effort to become more diverse. In 2017, the department made impressive progress, including a dramatic leap in the percentage of first-year residents from groups under-represented in medicine (UIM), from 15 percent to 28 percent.

We are constantly seeking new ways to help people find and create their community. Understanding and incorporating diversity into everything we do helps individuals and helps us become the strongest department possible. BETH HARLEMAN, MD

Commitment from the Top

“Department leadership has bought into the importance of this effort, and people put actions behind their words,” says Schaeffer. Those actions include creation of Harleman’s position, the hiring of Justin Moore, EdD, as the first staff and faculty experience specialist, and the recruitment of pulmonologist Meshell Johnson, MD, as the first director of diversity. Johnson, who brings a wealth of experience leading diversity programs both within and outside of UCSF, will work collaboratively with Harleman, Moore, and Schaeffer. “It’s also been transformative to have the larger institutional commitment,” says Harleman. “Every year the School of Medicine dean’s office reminds us how well we’re doing in reaching benchmarks for minority staff, residents, faculty, and fellows. We get data on numbers and culture. They

ask us to define an action plan – and we’re expected to improve. It really changes the conversation.” Harleman’s newly created position gives her an opportunity to further UCSF’s reputation as the most attractive place for all of the best and brightest applicants to build a career. That means making sure everyone understands how to access key resources, earn promotions, become a leader, and achieve work-life balance. For residents, fellows, and early-career faculty, this might translate into helping them find appropriate mentors or learn how to manage their money in a region with a high cost of living. For mid-career faculty, it might mean helping them refine their career path. “We start with some advantages,” says Harleman. “We have a unique and incredible culture, but we need to make sure people soak up what is great about this place.” “There is no lack of opportunity to make connections and find what you need, but our concern is for those who come from backgrounds where they don’t feel comfortable asking, or aren’t aware of how,” adds Schaeffer. “We should be proactive in saying, ‘Tell me what you want to do one or three years from now,’ and then commit to helping them get there.” Harleman agrees. “We are constantly seeking new ways to help people find and create their community. Understanding and incorporating diversity into everything we do helps individuals and helps us become the strongest department possible.”

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Diversity is critical throughout the health care workforce. As clinical providers, we are tasked with quickly engendering trust with people who may have lived very different lives from our own. AMANDA JOHNSON, MD, MBA

Doing the Hard Work of Culture Change

Despite leadership’s commitment, Harleman admits, “We haven’t always done a great job of being welcoming.” This is an oft-cited danger for under-represented minorities in prestigious organizations: Some can feel that the institution is doing them a favor by accepting them. “This especially hurts people who haven’t had the same opportunities, who might feel like they have to work harder than everyone else to be successful.” Harleman says that, in addition to creating clear road maps to success, UCSF must honestly recognize that, like the larger society of which it is a part, its culture is in flux. “We have to demonstrate that while we are not perfect, we are changing,” she says. In the past year, staff training on implicit bias and microaggressions, more diverse search committees, town halls where the department encourages honest discussions of the work climate, informal dinners at faculty

members’ homes, and a diversity-focused retreat were all part of a concerted effort to address concerns.

frame the need for diversity through the lens of service to our patients and our colleagues, this gives most people a way to engage.”

Those efforts include nonclinical staff. Moore has responsibility for developing and enhancing the diversity improvement and expansion efforts within the department and connecting them with UC and campuswide initiatives and programs. “Ultimately, by contributing to the dialogue and being present at the table where decisions are made, staff voices and perspectives will shape our support, training, and mentoring, as well as development of a stable pipeline for recruiting and retaining under-represented staff,” he says.

Schaeffer adds that changing culture also involves training champions for diversity among residents, fellows, faculty, and staff – and that this cannot be restricted to people from minority populations. Leadership opportunities are emerging across campus, and, Schaeffer says, “The responsibility should lie with all of us, both because of sheer numbers and because that’s how you demonstrate everyone embraces these ideas. It’s vital to a true culture of inclusion.”

Schaeffer says that in all of these efforts, “We have to create a space where we can talk honestly about why we don’t agree. In general, physicians have a sense of service, and that’s definitely the case here. So if we

Developing a Protective Shell

Amanda Johnson, MD, MBA, is the department’s chief resident for quality and safety. She completed her undergraduate studies at Stanford, her MD and MBA degrees at Harvard, and was a UCSF medicine resident before becoming chief resident in 2017.

I grew up in Milwaukee, the oldest of six girls. I developed a nascent understanding of what a doctor did during my mother’s pregnancies and while attending the well-child visits that followed. Medicine seemed to be a perfect combination of science and service. I had one excellent guidance counselor who provided practical, nuanced advice and unwavering support during the college application process, but I’ve also endured a number of paper cuts along the way. These included praise for my penmanship on those same college applications, and insinuations from my English teacher that my Canterbury Tales essay was too good for me to have written on my own. Comments like these taught me to develop a thick skin, which has continued to serve me from college through my residency training. Diversity is critical throughout the health care workforce. As clinical providers, we are tasked with quickly engendering trust with people who may have lived very different lives from our own. In addition to the direct benefits of diversity to our patients, a diverse workforce facilitates an ongoing institutional education in cultural humility as we learn to collaborate across our differences and teach each other how our unique perspective and experiences can enhance the care we provide. At UCSF, we still have work to do, but this is a very supportive department, an excellent training environment, and part of an institution that has found ways to make visible its commitment to diversity. These factors create the potential for real impact.

Reaching Out for Applicants

Reaching out effectively to potential applicants is another key piece of the puzzle. “We need to connect better with schools and institutions from which we haven’t had a pipeline before,” says Harleman.

drain the UIM pipeline from kindergarten through medical school, but at the residency stage, I think our department has worked to ensure that the pool doesn’t become too shallow too soon.”

Schaeffer again emphasizes the need for honesty with UIM applicants, whether it’s about the challenges and rewards of living in the Bay Area or frank acknowledgment that, for the most part, “Medicine remains a majority culture, and UIM applicants need to consider how they are going to balance their personal identity with that culture, as we work to make it more inclusive. When I came here, I knew the numbers at UCSF were small, but I recognized a program that could not be matched, a strong and growing Latino community, and an accepting LGBT community.”

Retaining a deep pool was an important element in the uptick in UIM interns for 2017. “We changed our selection process to review applicants not only by objective metrics, but also by life story, obstacles overcome, and commitment to community,” says Harleman. “What unique strengths and abilities does this person bring that we really want?”

Amanda Johnson, MD, MBA, the department’s chief resident for quality and safety, adds, “There is a range of hurdles that can

Review committee members also underwent implicit bias training to understand the lens through which they view applicants. “We

Changing the Application Process

can’t control everything, but we can make clear how all of us tend to use stereotyping, especially when we are tired and stressed,” says Harleman. To help address the reviewers’ extra workload, the committee used technology to help with the objective review of applicants. “That helped us concentrate on reading personal statements and understanding the whole person,” says Harleman. She adds the department is now talking about exporting this methodology to reviewing fellowship applications and, ultimately, to hiring faculty. “We’ve been a top program for years, and we need to remember that traditional measures don’t always predict a smooth course,” says Harleman. “We can open up a bit to pursue applicants who bring something to our department that we want and need – and we should have confidence that our program will help people grow skills and flourish.”

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When I started researching kidney disease, the majority of clinical research was on end-stage renal disease (ESRD) or transplant. Our biggest contribution has been earlier detection and prevention. M I C H A E L S H L I PA K , M D , M P H

Unique Collaboration Powers Groundbreaking Translational Research The UCSF Kidney Health Research Collaborative (KHRC) is a thriving example of how the Department of Medicineâ&#x20AC;&#x2122;s inclusive, multidisciplinary culture yields real-world benefits. Based at UCSF and the San Francisco Veterans Affairs Health Care System (SFVAHCS), the KHRCâ&#x20AC;&#x2122;s multidisciplinary team has become a major force for changing how clinicians perceive, prevent, screen for, and treat chronic kidney disease (CKD).

Carmen Peralta, MD, MAS Michael Shlipak, MD, MPH

Building a Team

As a general internist, Shlipak recognized early on that he would need to partner with a nephrologist. His opportunity came in 2004, when Carmen Peralta, MD, MAS, arrived at UCSF as a nephrology fellow.

Although it tends to fly under the radar, CKD affects more than 30 million Americans, most of whom will show no symptoms until they need dialysis or a kidney transplant due to kidney failure. It’s common among adults with diabetes and high blood pressure and disproportionately affects African Americans, Hispanics, and Native Americans.

“Carmen was explosive with ideas,” says Shlipak.

“When I started researching kidney disease, the majority of clinical research was on end-stage renal disease (ESRD) or transplant. Our biggest contribution has been earlier detection and prevention,” says Michael Shlipak, MD, MPH, chief of the Division of General Internal Medicine at the SFVAHCS and co-founder of the KHRC.

“He was such a generous mentor,” says Peralta of Shlipak. She eventually co-founded the KHRC and now serves as its executive director. “We come from very different backgrounds, but he helped me explore different ideas, and the hierarchy always stopped when we were having a scientific discussion.”

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Today’s Work

The KHRC’s work began with Shlipak’s successful effort to establish the links between CKD and cardiovascular disease. Today, its focus has expanded dramatically.

In academia, talented young researchers like Peralta often move to other institutions to begin independent research careers, including forming their own research groups. However, Peralta and Shlipak felt that their opportunity to change the lives of people with CKD was simply too great to break up the team. Ultimately, they decided to merge their budgets around CKD research to create the KHRC. “Within a year, my partner [an experienced operations and marketing professional] told me we really needed to expand and scale our work,” says Peralta. Michelle Estrella, MD, MHS

In part, that meant growing the capacity of the KHRC to serve as an incubator for career building. “Younger people tend to have the best ideas, and talented learners force you to think deeper,” says Shlipak. “The value of an idea here is not tied to seniority.” In addition, the two are in absolute agreement about the need for diversity at the KHRC. “If we don’t draw from diverse backgrounds, the questions will not be diverse, and that’s especially important for a disease like this,” says Peralta. Those principles have driven the KHRC’s growth. In less than a decade, with support from the Department of Medicine and the SFVAHCS, the group has nurtured four new academic faculty members, and served as the home for six NIH K awards for career development, eight NIH R-level (research grant) funded investigations, and three major foundation awards. Its output has been equally impressive, with more than 300 published journal articles. Nephrologist Michelle Estrella, MD, MHS, who joined the KHRC faculty in 2016, is an NIH-funded researcher with expertise in advanced kidney injury and adds another experienced person to the team. “In only one year, she has established herself as an excellent project leader and mentor,” says Peralta.

For primary prevention, projects include the development of tests that draw on novel biomarkers in urine and blood for detection of early kidney damage and injury. This includes exploring whether it’s possible to create a kind of “noninvasive biopsy” that measures specific proteins in the urine to quantify and localize damage within the kidney, such as medication toxicity, a major contributor to CKD. For secondary prevention, the group has developed a “triple-marker” testing strategy to identify persons at highest risk for CKD complications. It recently completed the first randomized clinical trial of this test to evaluate the efficacy of screening for kidney disease among veterans with hypertension who do not have diabetes. “Twenty percent had kidney disease, and neither they nor their doctors knew it,” says Shlipak. The KHRC is also pioneering two trials around the use of EHRs, including one, says Peralta, “that uses automated algorithms to prioritize screening tests and then connects test results to the proper treatment – again, with the aim to catch the disease much earlier than we do today.” Other research efforts include understanding and working to eliminate health disparities in CKD, and studying the complex interactions between CKD and hypertension, cardiovascular risk, and other chronic diseases, including HIV. “We formed the KHRC because there’s no way we can do this work on our own,” says Peralta. “The knowledge around kidney disease remains dangerously low, and if we’re going to change that, we need to continue to grow.”

We began using newer urine biomarkers to detect earlier injury, and had some really exciting preliminary findings: We may be able to detect specific kinds of injury and associate them with specific causes. VA S A N T H A J O T WA N I , M D

Nephrologist Vasantha Jotwani, MD, Joins the KHRC Team

In medical school, I fell in love with renal physiology and the complexity of patients with kidney disease. Early in my residency, I met Mike Shlipak, and we did a small study that eventually led to many other projects, mostly about HIV and kidney disease. During my NIH-funded research fellowship, we studied risk factors for kidney disease in people with HIV, with the understanding that as people with HIV infection live longer, they develop comorbidities, including CKD. This includes the fact that some antiretroviral medications could be a major contributing factor to CKD. We began using newer urine biomarkers to detect earlier injury, and had some really exciting preliminary findings: We may be able to detect specific kinds of injury and associate them with specific causes. I really appreciated the hands-on, comprehensive mentorship that I received from the get-go. There was so much honest, constructive feedback, as well as opportunities and introductions, which have helped me to collaborate with other leaders in the field. And as Iâ&#x20AC;&#x2122;ve developed my own interests and pursued them, KHRC leadership has offered nothing but support. Yet whatâ&#x20AC;&#x2122;s really kept me here is the team dynamic: getting paid to work with people I have a lot of fun with.

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Highlights from the Divisions Cardiology

Endocrinology/

Gastroenterology

Priscilla Hsue, MD, was appointed chair of the Clinical and Integrative Cardiovascular Sciences (CICS) Study Section of the National Institutes of Health.

Metabolism

The Gastroenterology Luminal Practice was the most improved in provider communication of all outpatient practice groups as defined by the UCSF Health FY17 incentive award program goal.

Binh An Phan, MD, received several notable teaching awards, including the Osler Distinguished Teacher Award from the UCSF School of Medicine Class of 2017, the Joel Karliner Faculty Teaching Award from the UCSF cardiology fellows, and the Floyd C. Rector Jr. Housestaff Teaching Award from the UCSF Department of Medicine residents. Rita Redberg, MD, MS, was elected to the National Academy of Medicine. The San Francisco VA Health Care System, one of the first VA medical centers in the country to start a transcatheter aortic valve replacement (TAVR) program, has now completed 153 TAVR procedures in a high-risk population, with a 0.65 percent mortality rate. One hundred percent of the patients cared for in the UCSF Cardiovascular Care and Prevention Center gave the center the highest possible rating, â&#x20AC;&#x153;highly likely to recommend,â&#x20AC;? in spring/summer 2017.

Mark Anderson, MD, PhD, received a MERIT Award for his R01 grant from the National Institute of Allergy and Infectious Diseases. Michael German, MD, received the Albert Renold Prize for pancreatic islet research from the European Association for the Study of Diabetes. Dolores Shoback, MD, received the 2017 Parathyroid Medal from the Fondazione Raffaella Becaglia (F.I.R.M.O.), in Florence, Italy, in recognition of her contributions to the pathophysiology, diagnosis, and treatment of parathyroid disease.

Uma Mahadevan, MD, became vice chair of the Immunology, Microbiology & Inflammatory Bowel Diseases Section of the American Gastroenterological Association, and section editor for the journal Gastroenterology. She was also chair of the Inflammatory Bowel Disease Planning Subcommittee for the American College of Gastroenterology/World Congress meeting in 2017.

Education

Kenneth McQuaid, MD, served as president of the American Society for Gastrointestinal Endoscopy.

Amy Berger, MD, PhD, received Chan Zuckerberg Biohub support to launch a molecular medicine consultation service.

Geriatrics

The UCSF internal medicine residency program nearly doubled the percentage of under-represented students who entered the program, from 15 percent to 28 percent.

Experimental Medicine Margaret Feeney, MD, was appointed to the American Society for Clinical Investigation.

Brook Calton, MD, MHS; Pei Chen, MD; Kathryn Eubank, MD; Daphne Lo, MD; and Edgar Pierluissi, MD, are 2017 Academy of Medical Educators Excellence in Teaching Award Winners.

Sei Lee, MD, MAS, received the American Geriatrics Society Thomas and Catherine Yoshikawa Award for Outstanding Scientific Achievement in Clinical Investigation. Christine Ritchie, MD, and Eric Widera, MD, were named Visionaries of Hospice and Palliative Medicine by the American Academy of Hospice and Palliative Medicine. Michael Steinman, MD, was elected to the American Society for Clinical Investigation.

General Internal Medicine Kirsten Bibbins-Domingo, MD, PhD, MAS, became the inaugural vice dean for Population Health and Health Equity in the UCSF School of Medicine, as well as the chair of the Department of Epidemiology & Biostatistics. Andrew Bindman, MD, served as director of the U.S. Agency for Healthcare Research and Quality (AHRQ). Denise Davis, MD, was inducted as an honorary member of the UCSF Gold-Headed Cane Society. Mitchell Feldman, MD, MPhil, received the Elnora M. Rhodes SGIM Service Award for outstanding service to the Society of General Internal Medicine and its mission of promoting patient care, research, and education.

Laura Fejerman, PhD, received the National Cancer Institute Center to Reduce Cancer Health Disparities Pacesetter Award for her discoveries regarding genetic ancestry and breast cancer risk in Latinas. Maria Garcia, MD, MPH, and Wagahta Semere, MD, MHS, were honored as John A. Watson Faculty Scholars, and received the School of Medicine Dean’s Diversity Fund Award. Michelle Guy, MD, and Ryan Laponis, MD, were inducted into the UCSF Academy of Medical Educators. Anna Maria Nápoles, PhD, MPH, has been appointed scientific director of the Division of Intramural Research at the National Institute on Minority Health and Health Disparities (NIMHD). Tung Nguyen, MD, was honored by Asian Health Services (AHS) for his life (starting with his family’s escape from Vietnam in 1975) and career with an inspiring video at the 2017 AHS gala.

Michael Rabow, MD, received the 2017 American Academy of Hospice and Palliative Medicine (AAHPM) Project on Death in America (PDIA) Palliative Medicine National Leadership Award.

Eric Small, MD, was elected to the American Society of Clinical Oncology Board of Directors.

Dean Schillinger, MD, received a Heroes & Hearts Award from the San Francisco General Hospital Foundation for promoting relationship-centered care.

HIV, Infectious Diseases

Vanessa Thompson, MD, and Alana Pfeffinger, MPH, received a California Department of Public Health film award for their video describing the UCSF Champion Provider Fellowship Program.

Hematology/ Oncology Alan Ashworth, PhD, FRS, was elected to the American Association for Cancer Research Board of Directors. He also received the 2017 Brinker Award for Scientific Distinction in Basic Science.

and Global Medicine Monica Gandhi, MD, MPH, launched Golden Compass at Ward 86 (UCSF’s HIV clinic at ZSFG), one of the first medical care programs in the U.S. for HIV patients who are aging. Bryan Greenhouse, MD, was named to the first cohort of Chan Zuckerberg Biohub investigators. Diane Havlir, MD, received the 2017 Distinguished Alumni Award from the Duke University School of Medicine. The PBS NewsHour series “The End of AIDS” – which features the work of Diane Havlir, MD; Steven Deeks, MD; the staff at Ward 86; others in this division; and their collaborators – won an Emmy Award for Outstanding Science, Medical and Environmental Report.

The Hematology/Oncology Service won the San Francisco Bay Area Federal Executive Board’s Employees of the Year Team Award. Andrew Leavitt, MD, received the Henry J. Kaiser Award for Excellence in Teaching in a Classroom Setting.

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Hospital Medicine Andrew Auerbach, MD, was elected to the American Society for Clinical Investigation. Megha Garg, MD, MPH, was elected to the American College of Physicians Patient Partnership in Healthcare Committee. Phuoc Le, MD, MPH, is one of 18 U.S. leaders selected as 2017 Eisenhower Fellows. Heather Nye, MD, PhD, was elected to the VA Hospitalist Field Advisory Committee. Steven Pantilat, MD, published Life after the Diagnosis: Expert Advice on Living Well with Serious Illness for Patients and Caregivers. Ami Parekh, MD, JD, was selected as one of 32 fellows of the California Health Care Foundation’s Health Care Leadership Program. Geoffrey Stetson, MD, received an Excellence in Clinical Teaching Award from the School of Medicine Class of 2017, and an Academy of Medical Educators Excellence in Teaching Award. Larissa Thomas, MD, was inducted into the UCSF Academy of Medical Educators.

Robert Wachter, MD, was named one of the 50 most influential physician-executives in the U.S. by Modern Healthcare magazine, his 10th year in a row on the list. He was also the commencement speaker at the University of Pennsylvania Perelman School of Medicine. Susan Wlodarczyk, MD, received an Academy of Medical Educators Excellence in Teaching Award. Charlie Wray, DO, MS, became associate editor at the Journal of Hospital Medicine.

Infectious Diseases Joanne Engel, MD, PhD, is the 2017 Philip Bassford Memorial Lecturer at University of North Carolina at Chapel Hill School of Medicine. Peter Chin-Hong, MD, received the Bridges Curriculum Foundations 1 Teaching Award for Outstanding Lecture Series. The UCSF 360 Wellness Center, directed by Malcolm John, MD, MPH, received the National Committee for Quality Assurance Level 3 Patient-Centered Medical Home recognition, the highest level of certification awarded by the committee.

Chaz Langelier, MD, PhD, won the Marcus Program in Precision Medicine Innovation Award. Richard Locksley, MD, was elected to the National Academy of Sciences. Oren Rosenberg, MD, PhD, was named to the first cohort of Chan Zuckerberg Biohub investigators. Brian Schwartz, MD, received a UCSF Excellence and Innovation in Graduate Medical Education Award, as well as the Kim Award, to promote well-being, rejuvenation, and work-life balance, from the UCSF Academy of Medical Educators. Paul Volberding, MD, was selected as the Alumnus of the Year by the University of Minnesota Medical School.

Nephrology Vanessa Grubbs, MD, published Hundreds of Interlaced Fingers: A Kidney Doctor’s Search for the Perfect Match. Carmen Peralta, MD, MAS, received an American Heart Association Established Investigator Award. Neil Powe, MD, MPH, MBA, is a 2017 fellow of the American Association for the Advancement of Science.

Occupational Medicine John Balmes, MD, was named director of the UC BerkeleyUCSF Joint Medical Program, the innovative pathway that combines an MS degree at UC Berkeley’s School of Public Health with an MD degree from UCSF. Paul Blanc, MD, MSPH, published Fake Silk: The Lethal History of Viscose Rayon, an exposé of occupational disease in the rayon textile industry.

Prevention Science Susan Kegeles, PhD, received the 2016 Academic Senate Distinguished Faculty Award in Mentoring. Marguerita Lightfoot, PhD, was appointed to the National Academies of Sciences, Engineering, and Medicine (National Academies) Committee on Fostering Healthy Mental, Emotional, and Behavioral (MEB) Development Among Children and Youth. Steve Morin, PhD, was awarded the UCSF Academic Senate’s Faculty Research Lecture in Clinical Science.

Greg Rebchook, PhD, and the UCSF Capacity Building Assistance Partnership team received the 1st place award as a CBA Brand Ambassador in recognition of their work promoting the Capacity Building Assistance network. Jae Sevelius, PhD, received the UCSF-Gladstone Center for AIDS Research 2016 Early Career Research Excellence Award for Social/Behavioral Science. Wilson Vincent, PhD, MPH, received the Center for AIDS Prevention Studies HIV Innovative Grant Award.

Pulmonary/Critical Care/ Allergy and Sleep John Fahy, MD, received a Recognition Award for Scientific Accomplishments from the American Thoracic Society, an award given annually for a lifetime of outstanding contributions to lung science. Meshell Johnson, MD, was named director of faculty diversity for the Department of Medicine. Dean Sheppard, MD, was elected to membership in the American Academy of Arts & Sciences.

Rheumatology Lindsey Criswell, MD, MPH, was named vice chancellor of research for UCSF. David Daikh, MD, PhD, was elected president of the American College of Rheumatology. Jonathan Graf, MD, was named Medical Honoree for the Arthritis Foundationâ&#x20AC;&#x2122;s 2017 Walk to Cure Arthritis â&#x20AC;&#x201C; San Francisco. Mary Margaretten, MD, received the Henry J. Kaiser Award for Excellence in Teaching in a Classroom Setting at UCSF School of Medicine. Renuka Nayak, MD, PhD, and Lin Shen, MD, PhD, were recipients of the American College of Rheumatology Distinguished Fellow Award. The Division of Rheumatology launched Precision Medicine in Rheumatology (PREMIER), an NIH/National Institute of Arthritis and Musculoskeletal and Skin Diseasesfunded center at UCSF with the overarching goal of facilitating and enhancing precision medicine studies in rheumatic diseases. Arthur Weiss, MD, PhD, was elected as an associate member of the European Molecular Biology Organization. Edward Yelin, PhD, was recognized as a master of the American College of Rheumatology.

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Reintegrating Subspecialty Medicine and Basic Science into Medical Education In September 2016, UCSF Department of Medicine Chair Robert Wachter, MD, published an article in the New England Journal of Medicine in which he and former Department of Medicine Chair Lee Goldman, MD, MPH, reflected on the remarkable growth of the hospitalist movement since they first described the emerging specialty in the same journal 20 years earlier. While they took pride in the many ways hospitalists have improved care, they also endorsed concerns that the specialty’s growth has led to “a diminished role for specialists and researchers on teaching services [so that] trainees have less…exposure to basic and translational science.” As pioneers in the field of hospital medicine – the fastest-growing specialty in medical history – the department is in a unique position to rethink that balance, so that trainees can still take advantage of hospitalists’ skills in care, education, and systems improvement, while also reaping the benefits of subspecialist and basic science exposure. Those benefits include grounding in the variety of thought processes that inform how outstanding clinicians operate and gaining a better understanding of how scientific advances are rapidly changing medical practice.

My goal is to make sure everybody has enough exposure to different specialties to make informed clinical decisions at the bedside, and to fully understand their career options. JENNIFER BABIK, MD, PHD

To promote this balance, in January 2017, the department created a new position and named infectious disease specialist Jennifer Babik, MD, PhD, its first associate program director for subspecialty education in the department’s internal medicine residency. “My goal is to make sure everybody has enough exposure to different specialties to make informed clinical decisions at the bedside, and to fully understand their career options,” says Babik. “Our outstanding general medicine and subspecialty training should not be mutually exclusive, but synergistic.” “Cross talk enriches clinical training, regardless of specialty,” agrees Lekshmi Santhosh, MD, a pulmonary and critical care fellow. Babik and Santhosh don’t believe there is one right balance, but they and others in the department are drawing on feedback from residents and fellows – and from a faculty that is passionate about teaching – to craft innovative pilots aimed at facilitating the synergies without adding to the burden of busy clinicians. The pilots include:

Lekshmi Santhosh, MD (right) with respiratory therapist Brian Daniels, RCP, RRT

Increasing subspecialists’ presence in clinical settings: One focus is increasing the

representation of subspecialist thinking in all of the department’s clinical settings, such as the daily morning report and morbidity and mortality (M&M) conferences. At ZSFG, for example, subspecialists participate in a focused case-based report for all internal medicine residents four out of five mornings a week. Chief residents at UCSF Medical Center at Parnassus, at ZSFG, and at the SFVAHCS quiz the residents each day with American Board of Internal Medicine-type questions, which each month focus on a different subspecialty. In addition, of the five resident teams on the teaching service at ZSFG, two always have a subspecialist attending backup. “It’s nice to have someone who has that additional skill set attending on a medical ward; it raises the bar on the conversation,” says Chief Resident Grant Smith, MD.

Jennifer Babik, MD, PhD (left) with medicine resident Anne Rohlfing, MD

Of course, getting subspecialists to attend can be a challenge. There are logistical headaches, and for many subspecialists, there is no real financial incentive – with the financial rewards higher for writing more grants or seeing more specialized patients in clinic or in the procedural unit. Nevertheless, says Babik, some subspecialists love the experience of working with trainees, and she views it as her responsibility to create those opportunities. Immersion electives: In the summer of 2017, the department began another pilot, in which residents can opt to spend block time immersed in a chosen inpatient or outpatient clinic, rather than running from setting to setting during their elective time. ZSFG Chief Resident Tejaswi Kompala, MD, cherishes that kind of exposure. “Because of my outpatient elective, I’ve decided to go into endocrinology,” she says.

Strengthening mentorship opportunities:

“Our mentoring programs are already working well, but to augment them we’re doing a number of different things,” says Babik. These include holding career interest nights for residents, where they can meet with program directors and faculty in subspecialties of interest. The department is also creating a mentor database, so residents can readily find people with whom they can connect.

Connecting residents and fellows: “Our

medicine residency and our fellowships are the best in the country, but we need more cross-pollination between these groups,” says Santhosh. To that end, Rachel Stern, MD, a former chief resident and now faculty at ZSFG, developed a lecture series on “a day in the life of a fellow,” where residents can get to know the fellows better. In addition, Babik and Santhosh put together a talk for interns on how best to communicate with subspecialty consultants.

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Piloting a Molecular Medicine Consult Service

The Molecular Medicine Consult Service (MMCS) is another new program intended to foster collaboration between clinicians and basic scientists. It launched in the summer of 2017. “It was originally the brainchild of one of our molecular medicine residents, Jake Appelbaum. He thought people should learn how to develop unifying scientific hypotheses to explain certain pathophysiology – and that certain clinical cases might effectively educate non-molecular residents about the current state of medical science,” says Neil Shah, MD, PhD, who directs the Molecular Medicine Residency program, the department’s physician-scientist training pathway. “We hope it will not only educate residents, but also help us to come up with diagnoses for a subset of these patients and generate new avenues of research.” The department is funding the project with help from the Chan Zuckerberg Biohub, which brings together scientists and engineers from UC San Francisco, UC Berkeley, and Stanford University and is co-led by Joe DeRisi, PhD, former chair of the Department of Biochemistry and Biophysics at UCSF.

Amy Berger, MD, PhD

30 Neil Shah, MD, PhD

Inspired by related programs, such as the UCSF Center for Next-Gen Precision Diagnostics and the NIH’s Undiagnosed Diseases Program, the MMCS draws on UCSF’s existing strengths, says hospitalist Amy Berger, MD, PhD, who leads the program. Berger will spend half her time this year building the MMCS and finding cases that match its mission.

The MMCS is comprised of a team that includes Berger, rheumatologist Mehrdad Matloubian, MD, and third-year MD/PhD degree residents, who will evaluate potential cases and serve as the communication link between clinical teams and scientific consultants. To help navigate UCSF’s expansive research enterprise, the MMCS has recruited a multidisciplinary advisory panel – which includes Shah, clinician-scientists from many medical subspecialties, and scientific leaders from neurology, genetics, laboratory medicine, pathology, and pharmacology. The MMCS will operate this year on the inpatient medical service at UCSF Medical Center, with the hope of eventually including other sites and referrals from ambulatory clinics. The triage teams will seek cases in which there is an unusual diagnostic dilemma, an extreme presentation of illness, or complex, multisystem disease without a unifying diagnosis. After evaluating the patient, conducting a detailed chart review, and discussing the case with the primary team and clinical consultants, the MMCS team conducts a literature review and reaches out to members of the advisory panel and

Researchers at UCSF are developing powerful new tools to dissect the molecular mechanisms of disease. These tools could revolutionize the ways we not only study but also diagnose disease.

ad hoc consultants in order to formulate a research question, research plan, and diagnostic recommendations. The hope is that by engaging scientists, clinicians will benefit from a deeper understanding of mechanisms of disease and be able to access cutting-edge experimental tools. Conversely, by addressing the problems of patients with unexplained diseases, scientists may uncover new targets for their work and accelerate the translation of experimental findings into diagnostic tools. “In our early cases, I’ve noticed that as clinicians, we tend to fall back on a systemsbased framework when we don’t understand something,” says Berger. “However, using physiology to guide clinical reasoning frequently leads to a complementary set of hypotheses.” She points to the case of a patient with HIV and lymphoma who developed diabetic ketoacidosis that did not respond to insulin. “The team suspected a complication of the patient’s lymphoma or chemotherapy, but it’s difficult to translate that hypothesis into a diagnostic or treatment plan. Once they started to think about the pathophysiology of insulin resistance, they thought, ‘Could this be due to rapid metabolism of insulin? Downregulation of the insulin receptor? Antibodies to the receptor?’ These hypotheses were much more useful for guiding testing and even treatment.” One of Berger’s priorities for this year is building partnerships with labs that are at the forefront of precision medicine. “Researchers at UCSF are developing powerful new tools to dissect the molecular mechanisms of disease,” she says. “These tools could revolutionize the ways we not only study but also diagnose disease.”

That said, she also worries about setting up false expectations. “I don’t want patients and clinicians to think this is like [the TV program] House and that we’ll be able to quickly and accurately provide a diagnosis,” she says. “A lot of these tools will live in the murky gray area between medicine and science for a very long time.” Yet even as Berger and the team navigate that tricky balance, she believes this challenge only intensifies the educational mission of the program. “The successful application of these tools will require a new level of collaboration between the people who understand the technology and the people who understand the clinical context,” she says. “It’s important for us to begin teaching physicians the basic principles of how these tests work, their benefits, and the unique challenges they present. We hope to cultivate the habit of mind of thinking mechanistically by embedding basic science education into active patient care and routine educational activities.” “I think it will go a long way toward exciting the community about what we can do at UCSF and inspire philanthropic donations,” says Shah. “Having people think out of the box, like Joe DeRisi – PhD researchers who are passionate about medical research – that’s what makes UCSF really special in an age of increasing convergence between our molecular understanding of biological processes and medicine.”

AMY BERGER, MD, PHD

U C S F D O M

Basic Research: Support for Risk-Taking Opens the Doors to Discovery The Molecular Medicine Consult Service and initiatives like it are driven in part by rapid advances in basic science research that uncover insights into disease process and change the way doctors think about disease. For 2017, the three department researchers profiled here offer examples of the startling breakthroughs contributing to that change.

Alexander Marson

Immunology researcher and infectious disease specialist Alexander Marson, MD, PhD, is developing and refining genome-editing technologies to understand how the human genome alters T-cell immune function. His work could lead to a new generation of targeted, cell-based therapies for cancer, HIV, primary immune deficiencies, and autoimmune diseases.

“I’ve always been fascinated by the basic question of how human cells specialize and how genetic information can disrupt a cell’s specialized functions,” says Marson, who is among the first group of investigators funded by the Chan Zuckerberg Biohub. He notes that genetic variants that contribute to human diseases are found not only in protein-coding genes, but also in the 99 percent of the genome that does not contain genes but does contain molecular “switches” that turn neighboring This place put such a strong emphasis genes on and off. on cultivating basic science and

integrating it with clinical applications that I was confident our collaborations could contribute to the future of medicine.

Marson’s work in human T-cell genetic control was catalyzed by his collaboration with UC Berkeley’s Jennifer Doudna, PhD,

an internationally known expert on CRISPR. Together, Marson and Doudna developed a CRISPR/Cas9-based technology that enables both “knockout” and “knock-in” genome editing in primary human T cells. The work has the potential – through molecular surgery or new pharmaceutical approaches – to enhance scientists’ ability to tune the cells, so they can fight against disease, rather than being turned off by disease processes. Marson says there are already plans to create a genome surgery center at UCSF for rare genetic diseases. “I came here as a Sandler Fellow because of UCSF’s culture of risk-taking, open exchanges, and great collaboration,” says Marson. “When I began looking for a faculty job, this place put such a strong emphasis on cultivating basic science and integrating it with clinical applications that I was confident our collaborations could contribute to the future of medicine.”

ALEXANDER MARSON, MD, PHD

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Richard Locksley

While we don’t yet have all the dots connected, we suspect there may be a number of therapeutic possibilities if we can figure out the various circuits involving ILC2s and how they work to keep cells and tissues healthy. R I C H A R D L O C K S L E Y, M D

As an infectious disease physician and immunologist, Richard Locksley, MD, was long fascinated by how little we knew about allergic immunity, including lack of understanding of evolutionary processes underlying host responses to parasitic worms (helminths) and environmental allergens. Armed with an understanding of the role of cytokines as the language of the immune system, Locksley – who in 2017 was elected to the National Academy of Sciences – began using genetically engineered mice to track cytokines expressed during allergic immune responses. This led to a number of important discoveries, most notably the discovery of a rare type of immune cell called group 2 innate lymphoid cells, or ILC2s, whose activation has been linked with allergic diseases such as asthma. More recently, his team discovered circuits linking ILC2s with

specialized epithelia in different tissues. In the lung, ILC2s activate lung epithelial cells that produce enzymes that break down chitin, a common environmental constituent of fungi and insects; the process may protect against age-related fibrotic lung disease by clearing the otherwise insoluble molecules from airways. In the small bowel, ILC2s respond to activation by tuft cells – previously enigmatic cells of the small intestine epithelia– to drive alterations in bowel physiology. “We’ve learned these cells participate in a number of previously unrecognized functions,” says Locksley. “While we don’t yet have all the dots connected, we suspect there may be a number of therapeutic possibilities if we can figure out the various circuits involving ILC2s and how they work to keep cells and tissues healthy.”

Mark Looney

In March 2017, the journal Nature published a groundbreaking article authored by the department’s Mark Looney, MD, a pulmonary and critical care physician and researcher interested in immune biology as applied to pulmonary disease. Looney and his team used video microscopy in a living mouse lung to discover that the lungs produce more than half of the platelets in the mouse circulation. Moreover, they identified a previously unknown pool of blood stem cells in the lung capable of restoring blood production when the bone marrow’s stem cells are depleted. Looney says the finding clearly suggests that the lungs are important in forming crucial aspects of blood. Thus, the work has significant clinical implications, including for thrombocytopenia, which afflicts millions of people and increases the risk of dangerous uncontrolled bleeding.

“We may be able to inject a patient’s own megakaryocytes, which are the precursors to platelets – developed from the patient’s own stem cells or from cord blood – and use the lung as a natural reactor to produce platelets,” says Looney. He adds that platelet decline in various lung diseases and in lung transplants could also be addressed with therapies that draw on this research. Looney is grateful that UCSF provided funding for a risky project through the Program for Breakthrough Biomedical Research. It also made available collaborators with expertise in imaging, hematopoietic development, and lung transplant microsurgery in mice. He says, “It’s not often that you can describe a fundamental physiologic process – and I don’t think it would have happened anywhere else.”

It’s not often that you can describe a fundamental physiologic process – and I don’t think it would have happened anywhere else. M A R K L O O N E Y, M D

U C S

Research Funding and Publications

F D O M

Research Grants

In 2016-2017, Department of Medicine investigators received 632 peer-reviewed grants and fellowships, as well as a combined total of 471 subawards, joint personnel agreements, and contracts, for a combined dollar amount of $422.4 million. Of that total, more than $200 million came from the National Institutes of Health (NIH), making the department the nation’s first to cross this threshold. These 10 grants were the largest.

1 — $

27.7M

Prescott Woodruff, MD, MPH; Stephanie Christenson, MD, MSc; Stephen Lazarus, MD; Chaz Langelier, MD, PhD; Joe DeRisi, PhD; and Mehrdad Arjomandi, MD, received a five-year, $27.7 million grant from the National Heart, Lung, and Blood Institute for SPIROMICS II, a national chronic obstructive pulmonary disease (COPD) clinical research network.

27.7 27.7MM

27.6 M

5 —

Kathleen Sarmiento, MD, MPH, and Mary Whooley, MD, received a five-year, $27.7 million grant from the Veterans Health Administration $ Office of Rural Health M for a national project to develop innovations in diagnosis and treatment of sleep disorders in geographically diverse populations.

Michael Matthay, MD; Kathleen Liu, MD, PhD; Carolyn Calfee, MD, MAS; Jeffrey Gotts, MD, PhD; Carolyn Hendrickson, MD, MPH; Rachael Callcut, MD, MSPH; and the Cardiovascular Research Institute received a four-year, $13.2 million grant from the Department of Defense for a project titled “Mesenchymal Stromal Cells for Treatment of ARDS Following Trauma.”

3 —

6 —

2 — $ $

4 —

Paul Volberding, MD; Steven Deeks, MD; Teri Liegler, PhD; Warner Greene, MD, PhD; Monica Gandhi, MD; Jonathan Fuchs, MD, MPH; and Jeff Milush, PhD, received a five-year, $15.2 million grant from the National Institute of Allergy and Infectious Diseases for the UCSFGladstone Center for AIDS Research.

27.7

Steven Deeks, MD; Peter Hunt, MD; Timothy Henrich, MD; Adam Abate, PhD; and Rick Hecht, MD, received a five-year, $27.6 million cooperative agreement from the National Institute of Allergy and Infectious Diseases for a project titled “Delaney AIDS Research Enterprise to Cure HIV.”

John Fahy, MD; Cathy Tralau-Stewart, PhD; Stephen Lazarus, MD; and key collaborators at University College Dublin and Trinity College Dublin received a five-year, $12.6 million grant from the National Heart, Lung, and Blood Institute for a project titled “CarbohydrateBased Therapy for Lung Disease.”

7 —

Marguerita Lightfoot, PhD; Mallory Johnson, PhD; Susan Kegeles, PhD; Torsten Neilands, PhD; and Greg Rebchook, PhD, received a five-year, $9.1 million grant from the National Institute of Mental Health for the Center for AIDS Prevention Studies.

8 —

Grant Dorsey, MD, PhD; Philip Rosenthal, MD; Bryan Greenhouse, MD, MSc; and Isabel RodriguezBarraquer, MD, PhD, received a six-year, $8.7 million cooperative agreement from the National Institute of Allergy and Infectious Diseases for the Program for Resistance, Immunology, Surveillance & Modeling of Malaria in Uganda (PRISM).

9 —

Stanton Glantz, PhD; Carolyn Calfee, MD, MAS; Michael Matthay, MD; Jeffrey Gotts, MD, PhD; Matthew Springer, PhD; Pamela Ling, MD, MPH; Neal Benowitz, MD; Gideon St. Helen, PhD; and the Cardiovascular Research Institute received a two-year, $8 million grant from the National Cancer Institute for a project titled “Improved Models to Inform Tobacco Product Regulation (TCORS).”

10 —

Steven Deeks, MD; Rachel Rutishauser, MD, PhD; Peter Hunt, MD; and Jeffrey Milush, PhD, received a five-year, $6.9 million cooperative agreement from the National Institute of Allergy and Infectious Diseases for a project titled “Therapeutic Vaccination and PD-1 Blockade in Treated HIV Disease.”

Publications

Department of Medicine faculty members published more than 3,300 peer-reviewed articles from July 2016 through September 2017. Here are the top 10 according to article-level citation metrics.

1 —

Günthard HF, Saag MS, Benson CA, del Rio C, Eron JJ, Gallant JE, Hoy JF, Mugavero MJ, Sax PE, Thompson MA, Gandhi RT, Landovitz RJ, Smith DM, Jacobsen DM, Volberding PA. Antiretroviral drugs for treatment and prevention of HIV infection in adults: 2016 recommendations of the International Antiviral Society-USA panel. JAMA. 2016.

2 —

Lessler J, Chaisson LH, Kucirka LM, Bi Q, Grantz K, Salje H, Carcelen AC, Ott CT, Sheffield JS, Ferguson NM, Cummings DA, Metcalf CJ, Rodriguez-Barraquer I. Assessing the global threat from Zika virus. Science. 2016.

3 —

Deeks SG, Lewin SR, Ross AL, Ananworanich J, Benkirane M, Cannon P, Chomont N, Douek D, Lifson JD, Lo YR, Kuritzkes D, Margolis D, Mellors J, Persaud D, Tucker JD, Barre-Sinoussi F; International AIDS Society Towards a Cure Working Group, Alter G, Auerbach J, Autran B, Barouch DH, Behrens G, Cavazzana M, Chen Z, Cohen ÉA, Corbelli GM, Eholié S, Eyal N, Fidler S, Garcia L, Grossman C, Henderson G, Henrich TJ, Jefferys R, Kiem HP, McCune J, Moodley K, Newman PA, Nijhuis M, Nsubuga MS, Ott M, Palmer S, Richman D, Saez-Cirion A, Sharp M, Siliciano J, Silvestri G, Singh J, Spire B, Taylor J, Tolstrup M, Valente S, van Lunzen J, Walensky R, Wilson I, Zack J. International AIDS Society global scientific strategy: towards an HIV cure 2016. Nat Med. 2016.

4 —

Fonner VA, Dalglish SL, Kennedy CE, Baggaley R, O’Reilly KR, Koechlin FM, Rodolph M, Hodges-Mameletzis I, Grant RM. Effectiveness and safety of oral HIV preexposure prophylaxis for all populations. AIDS. 2016.

5 —

Rugo HS, Olopade OI, DeMichele A, Yau C, van ’t Veer LJ, Buxton MB, Hogarth M, Hylton NM, Paoloni M, Perlmutter J, Symmans WF, Yee D, Chien AJ, Wallace AM, Kaplan HG, Boughey JC, Haddad TC, Albain KS, Liu MC, Isaacs C, Khan QJ, Lang JE, Viscusi RK, Pusztai L, Moulder SL, Chui SY, Kemmer KA, Elias AD, Edmiston KK, Euhus DM, Haley BB, Nanda R, Northfelt DW, Tripathy D, Wood WC, Ewing C, Schwab R, Lyandres J, Davis SE, Hirst GL, Sanil A, Berry DA, Esserman LJ; I-SPY 2 Investigators. Adaptive randomization of veliparib-carboplatin treatment in breast cancer. N Engl J Med. 2016.

6 —

Fujimura KE, Sitarik AR, Havstad S, Lin DL, Levan S, Fadrosh D, Panzer AR, LaMere B, Rackaityte E, Lukacs NW, Wegienka G, Boushey HA, Ownby DR, Zoratti EM, Levin AM, Johnson CC, Lynch SV. Neonatal gut microbiota associates with childhood multisensitized atopy and T cell differentiation. Nat Med. 2016.

Lobach IV, Hwang J, Pierce RH, Gratz IK, Krummel MF, Rosenblum MD. Tumor immune profiling predicts response to anti-PD-1 therapy in human melanoma. J Clin Invest. 2016.

8 —

Lynch SV, Pedersen O. The human intestinal microbiome in health and disease. N Engl J Med. 2016.

9 —

Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, Chaisson LH, Chaisson RE, Daley CL, Grzemska M, Higashi JM, Ho CS, Hopewell PC, Keshavjee SA, Lienhardt C, Menzies R, Merrifield C, Narita M, O’Brien R, Peloquin CA, Raftery A, Saukkonen J, Schaaf HS, Sotgiu G, Starke JR, Migliori GB, Vernon A. Official American Thoracic Society/ Centers for Disease Control and Prevention/Infectious Diseases Society of America clinical practice guidelines: treatment of drug-susceptible tuberculosis. Clin Infect Dis. 2016.

10 —

Collard HR, Ryerson CJ, Corte TJ, Jenkins G, Kondoh Y, Lederer DJ, Lee JS, Maher TM, Wells AU, Antoniou KM, Behr J, Brown KK, Cottin V, Flaherty KR, Fukuoka J, Hansell DM, Johkoh T, Kaminski N, Kim DS, Kolb M, Lynch DA, Myers JL, Raghu G, Richeldi L, Taniguchi H, Martinez FJ. Acute exacerbation of idiopathic pulmonary fibrosis. An international working group report. Am J Respir Crit Care Med. 2016.

7 —

Daud AI, Loo K, Pauli ML, Sanchez-Rodriguez R, Sandoval PM, Taravati K, Tsai K, Nosrati A, Nardo L, Alvarado MD, Algazi AP, Pampaloni MH,

U C S F D

Philanthropic Support to Department of

Medicine Faculty

Master Clinicians

Steven Schroeder, MD, received a $2 million donation from the Truth Initiative for the Smoking Cessation Leadership Center (SCLC). The SCLC takes a broad and collaborative approach to reducing the burden of smoking on health. Lloyd Damon, MD, received a $1 million donation from Barbara and Philip Oâ&#x20AC;&#x2122;Hay to establish the Nicole Oâ&#x20AC;&#x2122;Hay Endowed Fellowship in Hematologic Malignancies Research. This gift was made in memory of their daughter Nicole, who passed away from leukemia at age 45. Alka Kanaya, MD, received a $1 million donation from the family of a grateful patient to support her research on South Asian cardiovascular health. She plans to use this gift to expand the MASALA cohort study by enrolling second-generation young adults to determine the effects of acculturation on lifestyle factors and cardiometabolic risk. Charles Ryan, MD, received a donation of $1 million from a patient and his wife. The gift will be used to establish the Mr. and Mrs. Chow Kwen-Lim Fund for Advanced Cancer Therapeutics in the Genitourinary Medical Oncology Program.

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 2017 Master Clinicians were rheumatologist David Daikh, MD, endocrinologist Umesh Masharani, MD, MB, and gastroenterologist Francis Yao, MD.

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