Heroes

God wept. They trudged and limped into the clinic. Those that could, stood in line; others waited seated, filling the waiting area and corridors. Approximately 250 patients are seen at the rheumatology clinic at LAC (Los Angeles County Medical Center) + USC (University of Southern California) each week. Our nurses see another 150 patients weekly, and we average another 10 to 15 inpatient consultations each week.

Heroic Patients

Yesterday, we saw an Hispanic woman in her 50s who had over 30 years of terrible, nodular, erosive, destructive, progressive, unremitting, deforming rheumatoid arthritis with extra-articular disease. She had no health insurance coverage and came to our facility intermittently. There were long intervals of interrupted care when she returned to her native Mexico. We noted—and discussed with her and her family, who assisted her wonderfully—the difficulties she had with activities and self-care, her limitations, and her pain. We restarted disease-modifying therapy, nonsteroidal antiinflammatory drugs, and analgesics. We hoped to provide her what medication-induced amelioration we could and addressed rehabilitative issues as best we were able. We hoped she would return in a couple of months, adding to the already overscheduled appointments for that day. We hoped our general medicine clinics could provide a measure of primary care, knowing though that they were at least as overwhelmed as we were. As we left the room, frustrated at our inability to do more for this woman with whom life had dealt so harshly, she smiled from ear to ear and thanked us profusely.

We saw an African-American boy in his late teens who had developed systemic lupus erythematosus. He had been hospitalized elsewhere several years earlier for diffuse proliferative nephritis. Apparently, treatment was with “immunosuppressive” medication and high-dose corticosteroids. Being without income or health insurance, his subsequent care was intermittent, infrequent, and fragmented. We had a few incomplete records. He, with his mom, rode a sequence of buses across town over several hours for this appointment. He was ill, Cushingoid (still on steroids), and with all the clinical problems of active lupus. Superimposed were the economic challenge of obtaining care and medications and the social dilemma of trying to develop a life other than of chronic illness. We ordered studies to help assess his clinical status, resumed an “immunosuppressive” regimen, and determined to try to reduce his steroid usage. We spoke with him about returning to see us, and talked about continuing his education. As we left his room, frustrated at our inability to do more for this young man with whom life had dealt so harshly, he smiled from ear to ear and thanked us profusely.

The waiting time for new patients to obtain an appointment to see us can be as long as six to 12 months. Many of our patients are desperately ill, not necessarily in the sense of emergent needs, but from neglect by our systems and society, poverty, lack of education, and cultural ignorance. This is quite a change for me, coming most immediately from Livingston–Short Hills, New Jersey, home to one of the world’s most dense populations of millionaires. No fibromyalgia, regional musculoskeletal syndromes, or even osteoarthritis in the LAC clinics. No “boutique” care, “concierge” care, or “dollars-up-front” care for these folks coming to LAC, known as “The County.” We are their refuge, their salvation, their hope; there is no alternative. Whatever we provide separates them from total disregard. Whatever we do is more than they had. And they are profoundly grateful. Their courage, despite incredible adversity, is remarkable. They are heroes.

Heroic Physicians

It takes special people to care for such patients. Rheumatology at LAC + USC has been blessed with two such heroes of another kind. They have provided decades of stability, leadership, role-modeling, and mythic care. They have contrasting personalities and styles but shared a passion for providing the best possible care to this desperate population.

Frank Quismorio, MD, came here in 1967, after a fellowship with the legendary Joe Hollander at the University of Pennsylvania in Philadelphia. Frank was attracted to USC by the opportunity to study lupus with the renowned Ed Dubois, and was one of the founders of the LAC lupus clinic. Rheumatology at USC, and at LAC + USC, is unique because of Frank’s presence for the last 45 years. He has provided direction, consistency, and continuity to the rheumatology clinics. His quiet, self-effacing dedication, his exceptional clinical acumen, and his commitment to his patients have been a model of excellence for others at the medical center.

His encyclopedic knowledge of rheumatology has been the stuff of storied amazement. He displays a special ability to connect with patients, educate them, and help them understand their disease. He now has seen three generations of patients in several families. Despite the unfortunately transient nature of LAC patients, more patients return to us than to other clinics because of Frank’s influence. He greets most of the lupus patients and many of the others by name. Patients explicitly ask for him. He often encounters patients around town. He still has notes and card files on all his patients. He still calls them when necessary. He recalls going to patients’ homes when other means of communication failed. He does this because he cares, deeply. These patients, he says, “are at the bottom … we are the end of the line … they can’t be seen elsewhere … we are their safety net … they need our help.” Frank is deservedly proud of the many fellows he’s mentored over the years. It’s no surprise that his daughter, Anne, now sees patients with him in clinics; she’s a rheumatology fellow.

Another hero (more correctly, heroine, but her modesty would have her demur entirely) is Rodanthi Kitridou, MD. She came as directress of clinical rheumatology in 1975 (she retired in 2005), having previously trained with Dan McCarty, another of the seminal leaders in rheumatology, at Hahnemann University Hospital in Philadelphia, and with Joe Hollander at the University of Pennsylvania, while Frank, too, was a fellow there; she had directed rheumatology at Hahnemann (now Drexel) for five and one-half years.

Rodanthi complemented Frank. She was intense, clinically superb, smart, demanding, commanding, and obsessively thorough. Her knowledge of clinical rheumatology was vast and her clinical skills consummate. She was deeply devoted to her patients, with an almost maternal dedication. She would not tolerate her students, residents, or fellows not caring as assiduously as she, and woe unto him or her who stinted. She demanded a higher standard. Often was the time when she would seemingly spend hours with a patient, during a busy clinic day, sympathizing, empathizing, and displaying an amazing ability to figure out some novel way to help her suffering patients.

Closure of the rheumatology inpatient unit in 1994, a casualty of changing trends in medicine, deeply disturbed and disappointed Rodanthi. She, and her patients, perceived The County as patients’ home away from home and, in many instances, the only home they had. She too cared for generations of patients. She attended patients’ funerals. And weddings. For her, “medicine was a privilege, rheumatology a passion,” she says. Her influence was immeasurable. Three decades of fellows are exemplary clinical rheumatologists in large part because of Rodanthi.

Frank and Rodanthi are giants not only at LAC and USC but also within the ACR. Their masterships reflect their masterly devotion to patients and their masterly pedagogy. They have set the standard for care of patients in our clinics and, indeed, throughout our medical center and profession. Those students, residents, fellows, and faculty who come to rheumatology clinics know of their rich tradition and try, as Frank and Rodanthi did, to help patients as best they can to make patients’ lives a bit better. Frank and Rodanthi would be proud of their legacy.

And so, yesterday’s clinic ended, with patients departing, clutching their medications and return appointments, perhaps walking a bit more briskly, perhaps limping a bit less, perhaps standing a bit straighter. And God smiled.

Dr. Panush is professor of medicine, Division of Rheumatology, at the Keck School of Medicine, University of Southern California, in Los Angeles. He regularly writes “Rheum with a View.”