Faculty Spotlight: Rajni Rao, MD

Dr. Rajni Rao and team
Dr. Rajni Rao at center.  Photo credit: Elisabeth Fall.

Dr. Rajni Rao, ambulatory service chief for the Division of Cardiology, has a passion for elegant design – whether it's a mid-century pedestal table or a health care delivery system. "What I like about good design is that somebody has put a lot of thought into it, understands the needs of the end users, and does it with beauty," said Dr. Rao.

She brings that spirit of continual improvement to her leadership role in streamlining computer systems, work flows and other day-to-day aspects of the clinic which can be a source of constant frustration to patients and providers if poorly designed – or support the best doctor-patient interactions if optimized. By minimizing time wasted on inefficient processes, Rao strives to create an environment where the health care team can be fully present for the patient.

"'Efficiency' can be an impersonal word, but if it results in just one extra minute with a patient, it can be the difference between getting the diagnosis right or wrong, or making a connection with someone or not," said Dr. Rao.

She also envisions a future where doctors, nurses and other team members can use technology to offer more comprehensive care between visits – freeing up time during face-to-face visits for more substantial interactions.

"I don't like 'checkbox medicine,' where the patient comes in and we go down the list – 'Let me order this and that, check, check, check,'" said Dr. Rao. "My vision of future clinic visits is that all that is tucked in before they come, and we use our skills as diagnosticians and healers to say, 'Let's talk about your symptoms, your quality of life, your valve disease, your surgery – what do you want out of your life, and how can I help you achieve your goals?' It's a completely different way to practice medicine."

Team Effort

One concrete example of improving the patient experience is reducing wait times. When the clinic first opened in 2010, patients were routinely waiting 40 minutes just to get from the waiting area to an exam room. Dr. Rao and Brenda Mar, the clinic administrative director, worked together closely with their team to cut that time, which is now zero to 15 minutes. "There wasn't one day when the clinic suddenly improved, but we kept putting pressure on the system to improve, though there is a long way to go," said Dr. Rao.

Along with other colleagues throughout UCSF Health, Dr. Rao and Mar have completed Lean management training, a continuous process improvement model originally drawn from Toyota. Lean strives to maximize value to customers or patients, while minimizing waste.

"There is a Lean phrase, 'Go to gemba,' which is a Japanese word that means 'Go to the work floor and talk to workers,'" said Dr. Rao. "This is actually the most fun part of my job, and provides the highest yield – observing our staff and asking lots of questions. By stepping back and watching what people are doing, I find that people are often not able to take the straightest path from A to B. We can help simplify things for them that can also lead to downstream improvements for patients and providers. The next phase of Lean implementation is empowering front-line staff to actively recognize problems and suggest ways to improve. Employees who are not physicians have such a massive and underappreciated role in delivering health care – they are mission critical."

Part of this team approach is a daily 10-minute huddle, where staff gather around a whiteboard that serves as a "visibility board" to run through the day's quality metrics and the next day's game plan. They update stats like the number of patients waiting to be scheduled for appointments and the number of unfilled new patient slots, and ask a daily question such as "What is the correct method for checking blood pressure in clinic?"

"I've learned that the 20 or 30 minutes I'm in the room with a patient is just the tip of the iceberg," said Dr. Rao. "When there's churn in the system, by the time patients come see me, they can be anxious, and may not have had all the tests they need. Selfishly, I wanted to make clinic better for me, but I also realized I could have a role in helping the entire Division achieve its goals."

Inspiring Educators

Dr. Rao grew up in Dallas, then spent her teen years in Palo Alto where her father worked in the semiconductor industry. She earned her bachelor's degree in biology at Harvard in three years, minoring in women's studies with the intention of becoming an obstetrician-gynecologist.

During her first weeks at UCSF as a medical student, Dr. Rao studied the cardiovascular system with Dr. Kanu Chatterjee, a legendary clinician and teacher who died in 2015. Dr. Chatterjee asked for a volunteer to demonstrate the pulse exam, and Dr. Rao stepped up. "He demonstrated the correct technique, and his artful use of the physical examination and respectful patient interaction enraptured me," said Dr. Rao. "Even though I wasn't his patient, at that moment, I felt calm and cared for, and it was a really powerful experience."

As an internal medicine resident at UCSF, Dr. Rao was again inspired by watching Dr. Chatterjee on the Coronary Care Unit (CCU), and the mutual respect he shared with the CCU nurses.

Those interactions, as well as training with other cardiologists at UCSF, including Dr. Joel Karliner, Dr. Elyse Foster, Dr. Ann Bolger, Dr. Nora Goldschlager, Dr. Teresa De Marco and many others, inspired Dr. Rao to choose a career in cardiology. "I realized that cardiovascular disease is the number one killer of women, so it wasn't that big of a deviation to take my interest in women's health and apply it to cardiology," said Dr. Rao.

She completed her internship at Massachusetts General Hospital in Boston, then returned to UCSF for residency and fellowships in cardiology and advanced echocardiography.

She became intrigued by the puzzle-solving challenge of cardiac echocardiography, which is ultrasound of the heart. "Drs. Nelson Schiller and Elyse Foster have made echo such a core diagnostic test at UCSF that everybody from all over the hospital comes to the echo lab to understand cardiology," said Dr. Rao. "You feel a bit like a medical detective, looking at the image and trying to figure out who this person is, why they came in, why they fainted or had an arrhythmia. When you see the heart moving and you understand the physiology, everything else that seems abstract becomes real."

Dr. Rao relishes the rich educational environment of the echo lab, which has numerous medical students, residents, fellows, faculty and others coming through. "There's a lot of on-the-fly teaching of our craft and field, and it's just a really enjoyable place to work," she said.

Inspired by many educators at UCSF, Dr. Rao has become a leader in teaching the next generation of physicians, and received a Haile T. Debas Academy of Medical Educators Excellence in Teaching Award in 2014.

"My greatest joy is the on-one-one interaction with a student – sitting down with a student and deconstructing their experience and where they can go in their career and life, and where they can grow," said Dr. Rao. "I'm a straight shooter. We have to be the guardians of our own profession, and part of that is training people to hold the highest standards for themselves. I always tell people to give 120 percent, and even if you are doing well, that's good, but think about where you can push and challenge yourself."

Tailoring Care

In addition to teaching, interpreting echocardiograms, and working to improve clinic systems, Dr. Rao sees general and preventive cardiology patients. She has also developed an interest in cardio-oncology, or the care of patients with cancer who also have cardiac conditions. In collaboration with UCSF gastrointestinal oncologist Dr. Emily Bergsland and an interdisciplinary team, Dr. Rao and her colleagues provide tailored care for complex patients with rare gastrointestinal neuroendocrine carcinoid tumors, which produce hormones that can result in severe heart valve disease. They may be too frail for open heart surgery to repair or replace their faulty valves.

"We craft a plan for each patient, weighing the risks and benefits of doing something for their heart against how that will affect their overall function with the added burden of cancer," said Dr. Rao. One option is placing a prosthetic valve through a catheter, similar to the process used to implant a cardiac stent – which only requires a small incision in the groin, in combination with or in lieu of open heart surgery. "Maybe it doesn't fix the whole problem, but for complex patients, sometimes we need to be a little creative and come up with alternatives," said Dr. Rao, noting that this approach is investigational in this rare disease. She appreciates partnering with her heart team colleagues, including adult cardiothoracic surgeon Dr. Scot Merrick and interventional cardiologist Dr. Vaikom Mahadevan, to devise innovative approaches for these unique patients.

She brings that same creativity to her ongoing efforts to reimagine ways to provide care for a much more common condition: high blood pressure. In collaboration with the UCSF School of Pharmacy as well as partners across campus and industry, she is launching the UCSF HIPSTER (Hypertension – Innovating Personalized STrategies for Excellent Results) project. It will design and pilot a portfolio of engagement strategies to better manage patients’ high blood pressure in and out of the clinic. HIPSTER seeks to unobtrusively measure blood pressure at home, enable patients to make their own connections between lifestyle and blood pressure changes, and alert a care team when swift intervention is needed.

"We’re hoping to develop home-based monitoring and enhance patient communication with our care delivery," said Dr. Rao. "Patients should not have to wait months or years to get their blood pressure under control. That apparent lack of urgency can undermine the message we really wish to convey, which is that control of blood pressure is of paramount importance.

"On the other hand, office visits just to discuss blood pressure may be an outdated model for many patients," said Dr. Rao. "Not only is it inconvenient for patients, but increasing evidence also suggests that their blood pressure at home or at work – where they live their life – may be as or more important than the blood pressure we measure in clinic. We should continuously iterate on our methods to work with patients outside of the office to achieve their goals. We are excited to develop new technological tools to help us do this in ways that are convenient for patients and sustainable for clinicians."

HIPSTER is one example of how Dr. Rao wants to improve management of chronic disease. She also hopes to eventually offer a menu of options for patients, tailored to their needs and preferences for how their receive care. "If you want to come and see me, that’s fine," said Dr. Rao. "But if you are a busy working parent and can’t take time off from work, we can communicate through an app. If you’re a homebound senior and don’t speak English, maybe your daughter does and she is on email, so let’s recruit caregivers like her to help elderly people at home. The goal is to use technology to increase our communication and touch with patients, finding the right fit that’s individualized for each person."

Dr. Rao is married to Dr. Uday Kumar, a medical device entrepreneur who trained in cardiology and cardiac electrophysiology at UCSF. Dr. Kumar invented the ZIO® Patch, a wearable cardiac monitor used to detect abnormal heart rhythms. He is currently the founder, president and chief executive officer of Element Science and a consulting associate professor of bioengineering at Stanford University, where he also serves as the director of strategy of the Biodesign Program. Dr. Rao and Dr. Kumar live in San Francisco with their three young children, Sareena, Janavi and Rohan. In her rare free time, Dr. Rao enjoys listening to podcasts about design, perusing magazines like Dwell, and reading to her children.

– Elizabeth Chur