Hilde Berner Hammer – From ultrasound pioneer to professor emeritus
Hilde Berner Hammer has been a driving force in the development of modern rheumatology in Norway for decades. She is internationally recognized as one of the world's leading experts on the use of ultrasound in rheumatological diseases and has led groundbreaking projects such as NOR-CACTUS and the work on precision medicine at the REMEDY Center.
As a consultant at Diakonhjemmet Hospital and professor II at the University of Oslo, she has left a deep mark in research, teaching and clinical practice.
She is now retiring, but her commitment to the profession and her patients does not seem to diminish.
Communications advisor Kathrine Daniloff has had a chat about the past, present and future:
About the career
❓ What first sparked your interest in rheumatology – and how did ultrasound become such an important field for you?
– I was a LIS in medicine at RH and as part of my medical service I experienced the radiologist's mapping of pathology with ultrasound. I then thought that this method should also be used in rheumatology.
– On my first day as an employee at the rheumatology outpatient clinic, Diakonhjemmet Hospital, I tried to use ultrasound to look at my own joints. We were one of the few in the country that had an ultrasound machine at the time, thanks to our great teacher Oddvar Andrup.
– It took some time to understand the anatomy I saw using ultrasound, but I quickly realized that this method would give us fantastic opportunities to detect pathology in various joint diseases.
– After a lot of practice and some courses, my understanding of ultrasound increased significantly. It was really fun when I eventually got colleagues who were as curious as me, and together we explored what the different findings could mean in terms of pathology.
❓You have been instrumental in elevating ultrasound to a standard part of diagnostics. What breakthrough do you remember as the most crucial?
– In the beginning, most older general practitioners thought that ultrasound was an unnecessary examination, as they believed that the clinical examination was sufficient. But my experience was that there was a great deal of variation in how different general practitioners assessed the degree of illness in each patient, and I wanted us to become much more exact and similar in our assessments.
– There has not been any single event that I can say has been a breakthrough, but rather the daily experience of using ultrasound to assess patients has meant that we have learned something new almost daily and that together we have been increasingly able to become good at diagnosing different forms of pathology.
– Prof. Tore K Kvien, as the former head of the department, has been of great importance in increasing our ultrasound expertise by prioritizing the purchase of many ultrasound machines, and this has been continued by the current head Kjetil Bergsmark. The basis for becoming good at ultrasound and thereby improving our clinical assessment of patients is that an ultrasound machine is easily accessible, and preferably have one in every examination room.
– Today, most rheumatologists perform ultrasound as part of their clinical work, and perhaps this can be called a breakthrough; that the method has become part of the clinic? I must also praise the Norwegian rheumatologists; I think we may have the highest level of clinical use and knowledge within rheumatological ultrasound internationally.
❓ What has been your most exciting research project – and why?
– There have been many exciting research projects! A one-year follow-up study with ultrasound of arthritis patients who started with biological medicine gave me an incredible amount of experience with both ultrasound and patient-reported variables.
– A recently completed study of patients with gout, who were followed for 5 years, showed that the ultrasound-detected deposits of uric acid crystals (which are what cause painful attacks and joint damage) gradually disappeared under good drug treatment. I think this is an important study, as it provided knowledge and understanding that ultrasound can be used to detect the deposits of uric acid crystals and that the patients were motivated to continue with the medication when I could show them how the deposits gradually disappeared (and they were thus cured).
– NOR-CACTUS is also an important, ongoing study, where we are studying the effect of ultrasound-guided steroid injection versus surgery in patients with carpal tunnel syndrome. It is very nice to have a collaboration with orthopedists at the department!
About research and REMEDY
❓ How has the work at the REMEDY Center contributed to driving the field forward?
– I am very impressed with Prof. Espen Haavardsholm and the entire team that "founded" REMEDY!
– The division into 7 completely different working groups with their own leaders has resulted in a substantial research effort in many fields; from basic research/precision medicine, randomized studies, pain, comorbidity, registry research, digitalization to patient participation.
❓ You have worked extensively with precision medicine – how do you envision this will shape the future treatment of patients with joint diseases?
– There are major developments in basic research, with opportunities to study inflammation in tissue at the cellular level. Genetic characteristics can be mapped and thousands of proteins can be examined in blood samples.
– When we in the clinic have also developed a method for taking a biopsy of inflamed tissue, isolating cells in synovial fluid and blood samples, we, together with the basic researchers, will have the opportunity to assess the type of inflammation and thus be able to choose personalized drug treatment. This can have major positive consequences for our patients.
❓ What has the collaboration between different professional groups, such as rheumatologists and orthopedists in the NOR-CACTUS study, taught you?
– It is very nice to be part of a study together with orthopedists. We have a lot to learn from each other, and there is a very good collaboration in the NOR-CACTUS group, where all doctors, nurses and secretaries make a huge effort.
– It is also great to see how much research is now underway at the orthopedic department, and there is increasing collaboration between rheumatologists and orthopedists.
About teaching and professional development
❓ You have been committed to providing medical students with hands-on ultrasound training early on. Why is that so important?
– I want the clinical examination to provide the most accurate knowledge possible. There are many patients who have pain in different areas of the arms/legs, and we often hear that the GP has said that it is inflammation, without it being substantiated by imaging.
– This can make patients fear a serious illness. It could have been avoided if the GP, either himself or a cooperating colleague, could have performed an ultrasound of the painful areas and informed the patient that there was inflammation (which is rare, and which would perhaps have led to a referral to a rheumatologist), or normal conditions and that there was another explanation for the pain.
– Ultrasound could help GPs become better clinicians, and could also be of great help if there is a need for injection treatments.
❓ What do you hope the next generation of rheumatologists will take away from your way of working?
– I want them to become good at ultrasound and be able to diagnose musculoskeletal pathology, while also having a holistic understanding of the condition and that there are several forms of pain/discomfort.
– We should increase our knowledge in non-pharmacological treatment of pain/discomfort. I want us to have good routines in assessing the treatment effect for our patients where we distinguish between the effect on the immunological disease and the effect on relevant subjective complaints, so that we take a separate position on the treatment effect for both forms of pathology, and adjust further treatment accordingly.
About the transition to retirement
❓ How does it feel to go from a busy life as a researcher and clinician to retirement life?
– I have a 35% researcher position, but I am not yet down to such a low position fraction, as I have a good number of projects that it would be very good to have more time to work on.
– There will probably be a lot of projects in the next few years as well. But a fantastic advantage of being retired is the flexibility it gives in everyday life to also do other things.
❓ Do you plan to continue with research or teaching at any level?
– I will continue my research for at least a few years to come. I will also continue to teach courses, especially in ultrasound, where I have been invited for many years to a number of countries that are increasingly using ultrasound in rheumatology.
– I am also interested in pain, and have been teaching fibromyalgia patients about this disease for about 15 years. Now there is more and more happening on the pain front, and I want to continue to gather knowledge and pass this on.
❓ What will you miss most – and least – from working life?
– I miss the daily, pleasant environment among doctors, nurses and others in the rheumatology department, but it is also just nice research colleagues that I meet more now as a part-time researcher. The least I miss is having to work around the clock as head of the outpatient consultations at the outpatient clinic.
About the future of rheumatology
❓ What do you think are the biggest challenges and opportunities for Norwegian rheumatology in the coming years?
– I am very optimistic about the future as a rheumatologist; we have a profession where there are increasingly effective medications to reduce/cure inflammation, which is very motivating for clinicians.
– In addition, we have, among other things, highly sensitive imaging diagnostics that make it possible to make diagnoses early. In oncology, biopsies are taken to determine treatment. The hope is that we can also contribute in rheumatology with ultrasound-guided biopsies and that we will have basic researchers/pathologists who can then study the biopsy to inform about the best type of drug treatment.
– In terms of recruitment, we have a profession where the on-call work is quite tiring, which is probably attractive to many younger people. In addition, there are many exciting professional challenges and pleasant patients.
❓ If you could give one piece of advice to health authorities, what would it be?
– The mountaineering rules state: Listen to experienced mountaineers! I think the same should apply to political decisions within health; Listen to experienced professionals! Those closest to the field have the best opportunity to see improvements in the healthcare system.
