But ultrasound has long been an effective and accepted modality among many specialties, so what makes the Rheumatology Ultrasound Clinic distinct from other musculoskeletal ultrasound clinics?

“There’s actually a really big distinction. First and foremost, I’m a rheumatologist/immunologist. While most specialties use musculoskeletal ultrasound for soft tissue ailments like tendonitis, bursitis, and other joint abnormalities, rheumatologists are also trained to evaluate and manage conditions specific to our field, such as inflammatory arthritis or gout. So, we are often looking for very different things than other ultrasonographers.”

As a fellow in immunology and rheumatology, Rob Fairchild, MD, noticed something lacking in the care of rheumatology patients, and he set out to change that.

“The use of ultrasound by rheumatologists is more common in Europe than in the United States,” Fairchild observed. He was intrigued because ultrasound is a relatively easy tool that can be performed quickly in the clinic, and it’s an effective means for viewing soft tissue and other structures that can help rheumatologists with diagnosis and treatment.

“I did some training on ultrasound during my first year of fellowship, and that led me to devote one of my fellowship electives to starting a musculoskeletal ultrasound clinic dedicated to rheumatology evaluations and interventions,” he says.

Now, as the newest full-time member of the immunology and rheumatology faculty, Fairchild is seeing that the clinic continues not only for the benefit of patients, but also for the education of other trainees.

In fact, the American College of Rheumatology is moving toward incorporating ultrasound as part of rheumatology training, so Fairchild will be building that training into the fellowship curriculum.

The Craft So Long to Learn
The rheumatologist admits that ultrasound is very complicated and takes a long time to master. It requires learning separate views for each of the joints, and there are a lot of structures to know.

But ultrasound has long been an effective and accepted modality among many specialties, so what makes the Rheumatology Ultrasound Clinic distinct from other musculoskeletal ultrasound clinics?

“There’s actually a really big distinction. First and foremost, I’m a rheumatologist/immunologist. While most specialties use musculoskeletal ultrasound for soft tissue ailments like tendonitis, bursitis, and other joint abnormalities, rheumatologists are also trained to evaluate and manage conditions specific to our field, such as inflammatory arthritis or gout. So, we are often looking for very different things than other ultrasonographers.”

While Fairchild heads the clinic, two other attending rheumatologists—Jison Hong, MD, and Janice Lin, MD—also perform several procedures.

Evaluation and Treatment
Ultrasound helps Fairchild, Hong, and Lin when they are on the lookout for unusual disease manifestations like glandular disease in Sjogren’s syndrome, a debilitating condition that causes the eyes, mouth, or other parts of the body to dry out. It’s also useful in diagnosing polymyalgia rheumatica, an inflammatory disorder that causes muscle pain and stiffness, especially in the shoulders and hips. And ultrasound is a great aid in looking at temporal arteries to spot giant cell arteritis, which, if left untreated, can lead to blindness.

Two of the most frequent referrals the clinic receives are inflammatory arthritis evaluations and interphalangeal joint injections of the hands. 

In one recent case Fairchild was asked to evaluate whether there was evidence of an underlying inflammatory arthritis in a patient, as diagnosed by the patient’s previous rheumatologist.

According to Fairchild, “The patient had been on significant immunosuppression with a combination of steroids, methotrexate, and weekly TNF-alpha inhibitor injections, which all have the potential for serious side effects, require frequent clinical and laboratory monitoring, and are expensive. Our clinic’s ultrasound evaluation of the hands showed no synovial hypertrophy, synovitis, joint effusion, or erosions, which are the hallmarks of rheumatoid arthritis. Using this additional information coupled with the patient’s history and clinical evaluation, the referring provider at Stanford felt confident that the patient’s immunosuppression was not warranted and began to wean the patient off the medications.”

Another recent referral was for intra-articular injections for severe inflammatory/erosive osteoarthritis. “This aggressive, debilitating disease causes severe damage to the distal joints of the fingers with bony proliferation coupled with inflammation, pain, and dysfunction,” he explains.

“One way to reduce swelling, pain, and inflammation in these joints is through steroid injection. However, these joints are very small, and needle injection can be quite painful and technically challenging because of the bony mass surrounding the joint, making needle guidance difficult. When referred these patients, I use ultrasound to accurately guide the needle into the joint in one pass, greatly improving procedure tolerability and accurate steroid placement. As a testament to the efficacy and tolerability of these ultrasound guided procedures, I frequently have patients request repeat visits for additional therapeutic intervention once the steroid has worn off,” he says. 

‘Old’ and ‘New School’ Practitioners
Not everyone is convinced of the value of ultrasound.

Many rheumatologists are familiar and comfortable with “classic” examination techniques like feeling a patient’s joints for warmth, swelling, and tenderness to make an excellent diagnosis. “That’s very different from the ‘new school’ practitioners who can pull out an ultrasound and combine it with a clinical exam to give even greater accuracy. A lot of ‘old school’ rheumatologists would balk at that, but studies have shown that ultrasound is superior in finding active disease, particularly when the disease is mild, where it can be missed with a clinical exam alone,” Fairchild notes.

His interest in ultrasound is convincing other, more established rheumatologists that this technique is important for everyone to know and incorporate into their practice. In fact, some providers who may not have appreciated the value of ultrasound initially are now warming up to it.

Plans for Research
Several areas of research fit into Fairchild’s plans for the clinic. One has to do with how patients perceive their disease when they see it by ultrasound.

“I can tell patients that their disease is really active as a means of encouraging them to take a very serious medication, but that’s quite different from putting an ultrasound on them, pointing to the inflamed area and showing them how the joint is abnormal or damaged. They have an immediate response to that,” he says when explaining his desire to develop a research project in that area.

Another research interest involves scleroderma patients, who can be very sick with soft tissue and skin manifestations. There’s been a lot in the literature recently that has looked at ultrasound and how it can be used to assess disease, severity, the kind of disease that the patient actually has, and how it can help with treatments. Fairchild is pursuing a project in that realm with Lorinda Chung, MD, MPH, who runs Stanford’s Autoimmune Skin Disease Clinic in Redwood City with David Fiorentino, MD, PhD.

Training Tomorrow’s Ultrasonographers
Resident and fellow training is another facet of the ultrasound clinic.

“Coupled with their training in the clinic, we also do training at the bedside as part of Stanford 25,” says Fairchild. “Last year Dr. Hong and I did several musculoskeletal ultrasound teaching sessions for the residents in the hospital—hands-on things to show them how to look for knee effusions and other simple things that would be useful on the floor. I want to try to expand that as much as possible in the future.” 

While Fairchild heads the clinic, two other attending rheumatologists—Jison Hong, MD, and Janice Lin, MD—also perform several procedures.

Evaluation and Treatment
Ultrasound helps Fairchild, Hong, and Lin when they are on the lookout for unusual disease manifestations like glandular disease in Sjogren’s syndrome, a debilitating condition that causes the eyes, mouth, or other parts of the body to dry out. It’s also useful in diagnosing polymyalgia rheumatica, an inflammatory disorder that causes muscle pain and stiffness, especially in the shoulders and hips. And ultrasound is a great aid in looking at temporal arteries to spot giant cell arteritis, which, if left untreated, can lead to blindness.

Two of the most frequent referrals the clinic receives are inflammatory arthritis evaluations and interphalangeal joint injections of the hands. 

In one recent case Fairchild was asked to evaluate whether there was evidence of an underlying inflammatory arthritis in a patient, as diagnosed by the patient’s previous rheumatologist.

According to Fairchild, “The patient had been on significant immunosuppression with a combination of steroids, methotrexate, and weekly TNF-alpha inhibitor injections, which all have the potential for serious side effects, require frequent clinical and laboratory monitoring, and are expensive. Our clinic’s ultrasound evaluation of the hands showed no synovial hypertrophy, synovitis, joint effusion, or erosions, which are the hallmarks of rheumatoid arthritis. Using this additional information coupled with the patient’s history and clinical evaluation, the referring provider at Stanford felt confident that the patient’s immunosuppression was not warranted and began to wean the patient off the medications.”

Another recent referral was for intra-articular injections for severe inflammatory/erosive osteoarthritis. “This aggressive, debilitating disease causes severe damage to the distal joints of the fingers with bony proliferation coupled with inflammation, pain, and dysfunction,” he explains.

“One way to reduce swelling, pain, and inflammation in these joints is through steroid injection. However, these joints are very small, and needle injection can be quite painful and technically challenging because of the bony mass surrounding the joint, making needle guidance difficult. When referred these patients, I use ultrasound to accurately guide the needle into the joint in one pass, greatly improving procedure tolerability and accurate steroid placement. As a testament to the efficacy and tolerability of these ultrasound guided procedures, I frequently have patients request repeat visits for additional therapeutic intervention once the steroid has worn off,” he says. 

‘Old’ and ‘New School’ Practitioners
Not everyone is convinced of the value of ultrasound.

Many rheumatologists are familiar and comfortable with “classic” examination techniques like feeling a patient’s joints for warmth, swelling, and tenderness to make an excellent diagnosis. “That’s very different from the ‘new school’ practitioners who can pull out an ultrasound and combine it with a clinical exam to give even greater accuracy. A lot of ‘old school’ rheumatologists would balk at that, but studies have shown that ultrasound is superior in finding active disease, particularly when the disease is mild, where it can be missed with a clinical exam alone,” Fairchild notes.

His interest in ultrasound is convincing other, more established rheumatologists that this technique is important for everyone to know and incorporate into their practice. In fact, some providers who may not have appreciated the value of ultrasound initially are now warming up to it.

Plans for Research
Several areas of research fit into Fairchild’s plans for the clinic. One has to do with how patients perceive their disease when they see it by ultrasound.

“I can tell patients that their disease is really active as a means of encouraging them to take a very serious medication, but that’s quite different from putting an ultrasound on them, pointing to the inflamed area and showing them how the joint is abnormal or damaged. They have an immediate response to that,” he says when explaining his desire to develop a research project in that area.

Another research interest involves scleroderma patients, who can be very sick with soft tissue and skin manifestations. There’s been a lot in the literature recently that has looked at ultrasound and how it can be used to assess disease, severity, the kind of disease that the patient actually has, and how it can help with treatments. Fairchild is pursuing a project in that realm with Lorinda Chung, MD, MPH, who runs Stanford’s Autoimmune Skin Disease Clinic in Redwood City with David Fiorentino, MD, PhD.

Training Tomorrow’s Ultrasonographers
Resident and fellow training is another facet of the ultrasound clinic.

“Coupled with their training in the clinic, we also do training at the bedside as part of Stanford 25,” says Fairchild. “Last year Dr. Hong and I did several musculoskeletal ultrasound teaching sessions for the residents in the hospital—hands-on things to show them how to look for knee effusions and other simple things that would be useful on the floor. I want to try to expand that as much as possible in the future.”

“I was all for the possibility of a transplant from the beginning,” he says. “I was educated very well by the reading material that Stanford provided. They diagrammed what to expect and how successful things have been over the last several years.”

Sally Arai, MD, an associate professor of blood and marrow transplantation, was Gross’s physician. She talks about what kind of patient he was: “He presented for transplant with high-risk disease. What distinguished him was how very optimistic he was. He was just a lovely person from the beginning and very trusting. He started things off by saying, ‘Here I am and I know you can take care of me.’”

When Ron Gross went to his local hospital in Las Vegas in 2011 for routine tests prior to a cervical spine fusion, he had no idea how dramatically his life was about to change. Overnight he went from being a seemingly healthy middle-aged man to a seriously ill patient in need of a bone marrow transplant, then became a transplant survivor with an important new person in his life.

A blood test disclosed abnormalities soon determined to be myelodysplastic syndrome (MDS), a cancer of the bone marrow that affects its ability to make healthy blood cells. Gross needed an immediate transfusion of platelets to prepare him for the spinal surgery; soon thereafter he began 10 months of chemotherapy.

Gross talks about his experience in a matter-of-fact way: “At first everything seemed to be working with the chemotherapy, but I was needing supplementary infusions. My blood wasn’t working out too good as far as the counts went. As I progressed, I was averaging two to three transfusions a week of red blood alone and then platelets once or twice a week.”

The Frightening Search for a Bone Marrow Donor
It wasn’t long before his oncologist suggested that he needed to think about finding a donor for a bone marrow transplant. That’s when Gross began to do some research, ultimately deciding to come to Stanford in hopes of having that transplant.

“I was all for the possibility of a transplant from the beginning,” he says. “I was educated very well by the reading material that Stanford provided. They diagrammed what to expect and how successful things have been over the last several years.”

Sally Arai, MD, an associate professor of blood and marrow transplantation, was Gross’s physician. She talks about what kind of patient he was: “He presented for transplant with high-risk disease. What distinguished him was how very optimistic he was. He was just a lovely person from the beginning and very trusting. He started things off by saying, ‘Here I am and I know you can take care of me.’”

Gross started looking for a donor within his family—two sisters and a brother—and, he reports, “the best was eight out of 10 antigens from a sister. But that wasn’t going to be good enough for my condition, so they went to the Be the Match Registry.”

In February, 2014, Gross received his bone marrow transplant from a stranger who was a fully matched, unrelated donor and turned out to be from the other side of the world. His recovery went well, and he reports that he started to feel well about six months later. He had no episodes of rejection.

Arai points out how lucky Gross was: “Mr. Gross’s course was pretty smooth in terms of the transplant, just some minor ups and downs, but his overall attitude was just great. Fortunately, he never had to go beyond a fully matched unrelated donor. At the time of his transplant we didn’t have much to offer beyond a fully matched unrelated donor transplant, but that has since changed. For example, cord blood (using stem cells from umbilical cord blood) and haploidentical (partially matched) transplants became other approaches for us and increased our numbers of transplants dramatically.” (See the table.)

A Two-Year Wait to Meet His Donor
The rules about transplants dictate that donor and recipient cannot learn the identity of one another until, for international transplants, two years have passed. But Gross received many unsigned letters and cards from his donor and responded to them. On the day that he celebrated the second anniversary of his transplant, he dialed the phone number of his donor that he had been given. When the phone rang busy he hung up to try again in a few minutes, and his own phone immediately rang. His donor’s number was busy because she was dialing his number.

Karolina Wierciak lives in Szczecin, Poland. She signed up to be an organ donor in honor of a cousin who had lost his life to throat cancer. Because the rules in Poland reserve all donated organs for Polish citizens, she chose to enroll in a registry in Germany, making it possible for anyone in the world to receive her donation if she was a match.

Donor and recipient quickly found how alike they are, down to having birthdays two days apart. Recently Gross traveled to Poland and spent time with Wierciak, cementing their strong friendship. They are in touch via email and Facebook, and they text daily even now. As Gross says, “Even though she is the CEO of her company, working long hours, she decided to drive 211 miles to Germany and donate her bone marrow for international distribution, a decision that saved my life.”

The Field Continues to Evolve
Arai talks about the changes over just the last several years for patients with blood cancers. “For certain diseases, there have been recent exciting advancements like CAR-T cell therapy. That therapy is open to certain diseases like lymphomas and leukemias. But MDS, which was Ron’s diagnosis, is still treated with chemotherapeutic agents from many years back. Ultimately for a cure for these patients, it has to be a transplant.”

Patient characteristics have also changed to favor patients who were once considered too old to undergo transplant. “It used to be that transplants were for younger people who could handle the toxicity,” says Arai, “but now we have reduced-intensity transplants. Ron represents older patients, and they have become the norm for us. The average age is now in the 60s.”

So, Ron Gross was lucky on several levels. Perhaps the most important piece of luck to him was the opportunity to form his close relationship with Wierciak. Asked how he would introduce Wierciak to a friend, he says, “I would introduce her as my sister Karolina and my hero.”

The number of bone marrow transplants at Stanford, 2000–2016. The program started in 1987 and has both clinical and research significance: It is a national leader both in offering patients the most efficacious treatment and in advancing bone marrow transplant science.

A Two-Year Wait to Meet His Donor
The rules about transplants dictate that donor and recipient cannot learn the identity of one another until, for international transplants, two years have passed. But Gross received many unsigned letters and cards from his donor and responded to them. On the day that he celebrated the second anniversary of his transplant, he dialed the phone number of his donor that he had been given. When the phone rang busy he hung up to try again in a few minutes, and his own phone immediately rang. His donor’s number was busy because she was dialing his number.

Karolina Wierciak lives in Szczecin, Poland. She signed up to be an organ donor in honor of a cousin who had lost his life to throat cancer. Because the rules in Poland reserve all donated organs for Polish citizens, she chose to enroll in a registry in Germany, making it possible for anyone in the world to receive her donation if she was a match.

Donor and recipient quickly found how alike they are, down to having birthdays two days apart. Recently Gross traveled to Poland and spent time with Wierciak, cementing their strong friendship. They are in touch via email and Facebook, and they text daily even now. As Gross says, “Even though she is the CEO of her company, working long hours, she decided to drive 211 miles to Germany and donate her bone marrow for international distribution, a decision that saved my life.”

The Field Continues to Evolve
Arai talks about the changes over just the last several years for patients with blood cancers. “For certain diseases, there have been recent exciting advancements like CAR-T cell therapy. That therapy is open to certain diseases like lymphomas and leukemias. But MDS, which was Ron’s diagnosis, is still treated with chemotherapeutic agents from many years back. Ultimately for a cure for these patients, it has to be a transplant.”

Patient characteristics have also changed to favor patients who were once considered too old to undergo transplant. “It used to be that transplants were for younger people who could handle the toxicity,” says Arai, “but now we have reduced-intensity transplants. Ron represents older patients, and they have become the norm for us. The average age is now in the 60s.”

So, Ron Gross was lucky on several levels. Perhaps the most important piece of luck to him was the opportunity to form his close relationship with Wierciak. Asked how he would introduce Wierciak to a friend, he says, “I would introduce her as my sister Karolina and my hero.”

The number of bone marrow transplants at Stanford, 2000–2016. The program started in 1987 and has both clinical and research significance: It is a national leader both in offering patients the most efficacious treatment and in advancing bone marrow transplant science.

The new clinic’s patients are both similar to and different from those seen at Stanford, Sung says. “In Emeryville, I see a lot more patients with common lung ailments such as emphysema and asthma, some smoking-related, that we don’t see commonly at the Palo Alto campus. We also see a lot of complex lung diseases including pulmonary hypertension, lung fibrosis, and lung cancer in the East Bay. And we see general pulmonology problems that community pulmonologists would like us to consult with them about.”

Arthur Sung, MD, a professor of pulmonary and critical care medicine, spends a bit more time getting to some of his patients than he used to, and that’s fine with him. When he commutes to the multi-specialty Stanford Health Care Clinic in Emeryville in the East Bay, a variety of patients with diseases of the lung await him in a recently renovated building. The same is true for many of Sung’s colleagues at Stanford, and Sung is proud to describe what they have done as “a village effort, with early adopters and dedicated faculty. It is truly a programmatic and division integration of the community aligned with both the School of Medicine and Stanford Health Care’s vision.”

Sung explains the motivation for many Stanford pulmonologists to commute 40 miles to the East Bay to treat patients: “There was a need gap there in terms of both the presence of disease and the difficulty patients had accessing the Stanford campus. For patients in the East Bay it may be a short distance by absolute miles to go to Stanford, but because of the traffic it’s quite a chore to cross the bridges. So this was an underserved population, and that was the main stimulus for our coming to Emeryville. We wanted to offer a comprehensive pulmonary program that manages lung diseases from the more common to the more complex.”

The new clinic’s patients are both similar to and different from those seen at Stanford, Sung says. “In Emeryville, I see a lot more patients with common lung ailments such as emphysema and asthma, some smoking-related, that we don’t see commonly at the Palo Alto campus. We also see a lot of complex lung diseases including pulmonary hypertension, lung fibrosis, and lung cancer in the East Bay. And we see general pulmonology problems that community pulmonologists would like us to consult with them about.”

A Collaborative Relationship with Community Physicians
Critical to the success of the partnership at the Emeryville Health Clinic is a cordial and cooperative relationship among all the pulmonologists who practice there. Sung believes the groundwork for their success came from significant effort on all sides. He explains, “Stanford wants to establish close relationships with communities. From the beginning there was a lot of communication between us and the community physicians. This is a partnership. It isn’t really like cutting a pie; it is like sharing and treating the patients holistically.”

“We took many trips to Emeryville to reassure that we were not there to take away business; we were there to add tertiary care. Patients often come to us for just a consultation and then go right back to their community pulmonologist. We don’t keep patients unless it’s necessary; for example, the community pulmonologists don’t really have the bandwidth to take care of diseases like lung fibrosis and pulmonary hypertension, and we can provide those resources.”

Designing the Pulmonary Clinic
In addition to enhancing the local lung disease expertise, all the pulmonologists had the common goal of being able to care for their patients in a completely renovated, state-of-the-art building. Working jointly on that project meant that, as Sung says, “both the community physicians and the Stanford physicians had a lot to say about the design. We had multiple sessions to discuss both the type of patients we wanted to serve and the way they would flow through the building. We took trips to some of the more progressive centers across the country to see how they did things so that we could emulate them.”

The building’s design ensures that patients have a smooth and logical pathway from the entrance to the building to their discharge after being treated. As Sung sees it, “The patient flow is very well thought out. We are able to deliver very simple care and handle diseases that require a lot more expert testing, such as biopsies and procedures, as well as those needing advanced CT scanners and operating rooms. We have all of that.”

Exposure to Community Medicine for Trainees
Emeryville also offers a different opportunity for younger doctors than clinics at Stanford. Because of the complexity of so many patients with lung diseases who travel to Palo Alto, Sung believes that “the fellows sometimes miss the opportunity of seeing how it would be practicing in the community. Having Emeryville is a win-win situation. Not only do we provide complex care, but that exposure to community medicine is there for our fellows to experience as well.”

Chunrong Lin, MD, a clinical assistant professor of pulmonary and critical care medicine, agrees that the Emeryville population is different. “At Emeryville I see patients from Oakland, where there are a lot more African Americans than I see at Stanford. I am seeing some patients with severe asthma who have never seen an asthma specialist, and I’m able to introduce them to some new therapies.”

Sung’s own practice in Emeryville mirrors his practice at the main campus. As Sung says, “I do interventional pulmonology for patients who require minimally invasive procedures such as bronchoscopy, severe asthma, lung nodules, and emphysema.”

Sung returns to the unique characteristics of the situation in Emeryville and the advantages it offers both patients and their physicians: “It is uncommon to have such a comprehensive building as we have in Emeryville that provides a lot of the things that you would otherwise send the patient back to the main campus to be tested for.”

The Stanford Health Care Clinic, Emeryville offers every subspecialty of Stanford’s pulmonary program, and each subspecialty is led by Stanford physicians.

Designing the Pulmonary Clinic
In addition to enhancing the local lung disease expertise, all the pulmonologists had the common goal of being able to care for their patients in a completely renovated, state-of-the-art building. Working jointly on that project meant that, as Sung says, “both the community physicians and the Stanford physicians had a lot to say about the design. We had multiple sessions to discuss both the type of patients we wanted to serve and the way they would flow through the building. We took trips to some of the more progressive centers across the country to see how they did things so that we could emulate them.”