When Pulmonary and Critical Care Medicine Division Chief Brian Graham, MD, steps into the intensive care unit of the Zuckerberg San Francisco General Hospital, patients and clinicians alike look to him for guidance. If he’s not in the ICU, you might find him in the research lab, conducting pivotal studies and forging global partnerships to uncover mysteries of an understudied parasitic disease. And when he isn’t in the hospital or research lab, you may see him in a lecture hall at the University of California San Francisco, teaching the next generation of doctors how to become an exceptional physician.
The many hats that Graham wears are proof of his multifaceted skill set, much of which he credits to his training and early-career faculty experience at the University of Colorado Department of Medicine.
“The training I got was top notch,” he says. “It promoted independence, critical thought, and offered a great balance of clinical care and research development. It was outstanding.”
‘Unbelievably good’ training
Part of what drew Graham to join the CU Internal Medicine Residency Program in 2004, besides the scenic mountains, was the reputation of the Division of Pulmonary Sciences and Critical Care Medicine.
Graham’s interest in pulmonology, a medical specialty that focuses on the respiratory system, sparked during his training at Harvard Medical School. He took a pulmonary sciences class that reminded him of lessons he learned as an electrical engineering student at the Massachusetts Institute of Technology, where he received his undergraduate and master’s degrees.
“There are aspects of pulmonary physiology that are similar to engineering, such as looking at fluid flows and interacting systems, and I really liked it,” he says. “Then, I did an elective in critical care medicine and really enjoyed that experience.”
Upon joining CU, Graham’s interest in pulmonary medicine grew as an internal medicine resident and, subsequently, as a fellow in pulmonary sciences and critical care medicine. Through his training and introduction to new mentors, he found a particular interest in pulmonary hypertension — a condition where the blood pressure in the lungs is higher than normal, potentially causing damage to the heart.
Graham knew he wanted to conduct research, and when he began his fellowship training, Mark Geraci, MD, who was the division head of pulmonary sciences and critical care medicine at the time, recommended Graham connect with Rubin Tuder, MD.
“I joined Rubin’s lab, and we hit it off. Under his mentorship, I learned the basic techniques of laboratory science during my fellowship and was able to continue going from there,” Graham says.
In addition to honing his research skills, he also was learning from key experts — such as David Badesch, MD, and Todd Bull, MD — how to be an exceptional clinician who prioritizes patient care.
He also had the opportunity to give back to the residency and develop educational skills by serving as an associate program director for the CU Internal Medicine Residency Program, with focus on promoting research by trainees, under the leadership of Suzanne Brandenburg, MD, and David Schwartz, MD.
“The clinical training I got as a resident and fellow was outstanding, and that’s the foundation on which other areas, research and education, derives,” Graham says. “I really enjoyed the experience, and CU’s training continues to be unbelievably good.”
From trainee to division chief
After completing his fellowship in 2010, Graham remained at CU for the next nine years and continued his research, teaching, and clinical work until he was ready for his next challenge: becoming a leader at a new hospital.
In 2019, Graham became a professor in residence at the University of California San Francisco (UCSF) and joined the Zuckerberg San Francisco General Hospital and Trauma Center as chief of the division of pulmonary and critical care medicine. He describes the hospital as similar to Denver Health, as it is also a safety-net hospital (meaning medical care is provided to people regardless of their ability to pay).
“We have 20 faculty in our division, and we’re closely associated with the main UCSF campus, but we have our own independent culture, resources, and research facilities,” Graham says. “I arrived in July of 2019 and had about six months to really understand my role as division chief before the COVID pandemic hit.
“When COVID happened, I wasn’t the new guy anymore. Instead, I was front and center as the pulmonary division chief in the pandemic. It was a very challenging and difficult period of time for the next two years, but we emerged from that and have worked to find a new normal,” he adds. “We still face constraints in terms of clinical operations funding, so a lot of my job is negotiating for clinical resources to adequately staff our ICU and other services.”
A key part of his role as division chief is helping his team succeed, Graham explains, whether it be through getting clinicians the resources they need, protecting their time to conduct research and prevent being overworked, and providing guidance as they transition into new career positions.
“I think the mark of a good division chief is someone who helps all their division’s members advance in their careers. I try to be generous with my time and provide advice that I would’ve found helpful when I was at their career stage, because it can be a hard process to navigate,” he says.
A group photo of the Zuckerberg San Francisco General Hospital Pulmonary Division in March 2023. Top row (left to right): Christopher Berger, Joshua Vasquez, Priya Shete, Neeta Thakur, John Metcalfe, Christine Yoon, Carolyn Hendrickson, Patrick Phillips, Richard Wang, and Rahul Kumar. Bottom row (left to right): Antonio Gomez, Payam Nahid, Lisa Chen, Courtney Broaddus, Phil Hopewell, Brian Graham, Jenny Fowler, Laurence Huang, and George Su. Not shown: Kamran Atabai, Elizabeth Fair, Midori Kato-Maeda, and Michael Lee. People wore bow ties in memory of John Murray, the first division chief, who passed away in 2020 due to COVID.
Prioritizing patients
In the hospital, when Graham isn’t working on improving systems for other clinicians, he is working to provide the best care possible for patients he serves in the ICU, as a clinical pulmonary consultant, and in the outpatient chest clinic. He prioritizes teaching other clinicians to do the same.
“My clinical work and teaching others how to do clinical work has been really rewarding. It’s something I pride myself in,” he says.
One of his proudest achievements in the clinical space has been developing and growing a collaboration between his team and another hospital in San Francisco called the Chinese Hospital.
“It’s a historic hospital that started over 100 years ago. The Chinese community in San Francisco was burgeoning at that time, but they were having trouble accessing health care, so they started their own medical system,” Graham says. “We help attend in their ICU and we have a pulmonary clinic there. It’s a great group to work with, and I think we're making a real impact in their hospital. I’m hopeful that we can continue to work with them and develop our relationship.”
Uncovering mysteries of an understudied disease
If it wasn’t for Graham coming to CU, he may have never chosen to research an understudied disease called schistosomiasis — a type of lung blood vessel disease caused by parasitic worms.
“My mentor, Rubin Tuder, was the person who told me about it and suggested that I study it, and I’ve been in this field since 2008,” Graham says.
According to the World Health Organization, people become affected with schistosomiasis when the parasite, which is released by freshwater snails, penetrate a person’s skin during contact with infected water, and the worms develop in the blood vessels. The disease is prevalent in tropical and subtropical areas, especially in communities without access to safe drinking water and adequate sanitation. Transmission of the disease has been reported from 78 countries.
Graham focuses much of his research on schistosomiasis-associated pulmonary hypertension. For the first decade of his research, he worked to uncover the molecular pathways by which the parasite would cause lung blood vessel disease in animal models. Part of this work is funded by a grant shared with CU, led by Kurt Stenmark, MD, in the Cardiovascular Pulmonary Laboratory.
“We essentially investigate the immunology of this infection in mice. Based on our research, we think that the parasitic infection causes the host immune system to become activated, and the blood vessels are an innocent bystander that are adversely affected by the same immune signaling pathways that cause pulmonary hypertension in other forms of the disease,” he says.
Now, Graham is working to expand his investigations into clinical research, hoping to better understand how humans are affected by the disease.
“There are fundamental questions in the human disease that we’re trying to answer like: How common is this disease? Why do some people get this disease and others don’t? How does it relate to what we’ve identified in mice?” he says. “We’re also trying to find ways to diagnose and identify new treatments for the condition.”
Forging global research partnerships
In order to answer the lingering questions about schistosomiasis-associated pulmonary hypertension in humans, Graham has developed collaborations with investigators in Brazil, Ethiopia, and Zambia.
“A lot of the work in pulmonary hypertension, clinically, has been in the U.S. and Europe, which generally have a lot of resources. In particular, there is a procedure, right heart catheterization, needed to diagnose the condition. At an institution like CU, this is done routinely, but in other places of the world, many countries don’t have access to it,” Graham says.
In Ethiopia, a low-income country that has a population of more than 128 million people, only two of these procedures were done in the past year, he explains.
“Together, we need to figure out what the disease looks like in their setting when you can’t do procedures like we can do. That’s why we collaborate with them,” he says. “We have an active research project where we’re relying on ultrasound of the heart, called echocardiography, to try to figure this out. We’re also considering alternative ways to diagnose the condition, or ways to expand the ability to do the right heart catheterization.”
Zambia, which is considered a low-middle income country, can do some right heart catheterization procedures, but it is not a routine procedure, Graham explains, saying: “They have supply issues, because they need catheters to be able to do the procedure.”
In Brazil, an upper-middle income country, the larger cities can do the procedure relatively routinely, but rural areas often cannot.
“The parasitic infection that we study is most endemic in rural settings. And so, there are still unanswered questions about who’s getting diagnosed with the condition and how to diagnose it effectively,” he says.
A unique aspect of the partnership with Brazil is that, as part of Graham’s ongoing work to better understand schistosomiasis-associated pulmonary hypertension in humans, researchers in Brazil are collecting blood specimens and sending them to Graham’s partners at CU, such as Claudia Mickael, PhD, who then work to analyze the specimens and share results with Graham and his team.
“I’ve had the chance to meet some fascinating people through these partnerships, and it’s been really rewarding to work with them,” he says.
When Graham reflects on his career thus far, he shares that a key ingredient to his success was developing strong clinical and research skill sets early on. His advice to future clinicians and scientists is simple: “Focus on what you’re good at and get the fundamentals down, but also try to be aware of the bigger picture and opportunities to advance your career.”
