If Joe the Plumber Gets Arthritis

I apologize if you are sick of political references, but I couldn’t resist the one in the title of this article. The other title that I was considering for this Rheumination, “Personalized Medicine in an Era of Fiscal Constraints,” sounded like a snoozer. No doubt about it, with that ponderous title, your eyes would have zoomed right on by.

If a disquisition on Joe the Plumber’s bodily woes piqued your interest, thank you for stopping here. I hope that you will keep on reading because I have tried to put in important stuff. To the trainees who are reading, I would like to offer a special welcome. Also, I am happy to inform you that this column highlights one of the core competencies, systems-based practice, although I confess I had to look up what that was.

Joe the Plumber asks Barack Obama a question about taxes during a campaign stop.

Joe the Plumber is now one of the most famous people in America. In case you spent the 2008 campaign season on Mars or under a rock, let me provide some details. Joe the Plumber is basically an ordinary Joe (pun intended) who asked then-presidential nominee Barack Obama a question about taxes during a campaign stop. John McCain and Sarah Palin latched onto this episode and made Joe a touchstone of their speeches. Then, through amplification and reverberations of the media, Joe became an archetype of working-class America and has been enshrined as an iconic figure, along with Joe Six Pack and GI Joe. Unlike that of many other instant celebrities, Joe the Plumber’s fame has lasted far more than 15 minutes. Indeed, it has somehow extended well beyond 15 hours and 15 days but, unless Joe’s agent gets him a few gigs or Joe throws his hat into the proverbial political ring, 15 weeks of fame may be out of reach.

If Joe retreats from the white hot light of media attention to resume his old life, he will again spend his day unclogging stuffed toilets and installing garbage disposal units instead of opining on government policy. Back on the job, he will get wet, crawl around the concrete basement floors, and wield big wrenches, with all that torque freeing stuck valves stressing and straining vulnerable joints. In putting his joints at risk, Joe will be like other patients in the building industry—Charlie the Carpenter, Ron the Roofer, and Pete the Plasterer—and will be a set-up for arthritis of the degenerative kind. When this affliction sets in, Joe’s body will get stiff, his knuckles will swell, and plumbing work will become excruciating as every twist and turn of his tools sends shocks of pain into Joe’s joints. (Looking at Joe’s physiognomy, I would not be surprised if he also develops some gout. My recommendation: Watch out for the brewskis, pal.)

When Joe Calls the Rheumatologist

At some point, Joe’s attempt to quell his pain with over-the-counter acetaminophen and nonsteroidal anti-inflammatory drugs will fail. He will decide that enough is enough, and he will go see the doctor. For you readers in the great state of Ohio, be prepared. He may show up in your office.

The questions I would like to ask in this and the next column are, what kind of healthcare would Joe like and what kind of healthcare will be available? (Trainees, this is system-based practice).

During the ACR meeting in San Francisco, I attended a brilliant lecture by Iain McInnes of Glasgow, Scotland. In his year in review, Iain talked about the aspirations of patients for better treatment. According to Iain (and I would agree), patients seeking rheumatological care do not want the best therapy for rheumatoid arthritis. They want the best therapy for their rheumatoid arthritis.

This desire—shared by patient and physician alike—is at the heart of personalized medicine. In the realms of basic and translational research, personalized medicine is emerging as a major enterprise and intellectual focus, with current genetic and genomic techniques providing an unparalleled picture of the cellular and molecular basis of illness in any Joe or Josephine. Indeed, according to projections of the avant garde, it will soon be possible to genotype and phenotype people completely and put all the necessary gene sequences, SNPs, and microarrays on a little chip to be stuffed into a wallet just like a credit card. If all goes as planned, the chip will be a personal rosetta stone to help the physician predict outcomes and devise the best therapy for the patient. For example, the chip will pinpoint, on the basis of pharmacogenetic and pharmagenomic data, which one of the currently three (soon to be five) tumor necrosis factor blockers has the greatest chance to get the Disease Activity Score to 2.6 without wakening red snappers from their slumber.

In its essence, personalized medicine is prototypically American. In a way that Joe the Plumber would like, personalized medicine is about the individual, and it is founded on the idea that optimizing the health of each and every individual will optimize the health of the nation.

Personalized Economics, Personalized Medicine

In his famous tête-à-tête with Barack Obama, Joe the Plumber discussed a related subject—personalized economics—querying the soon-to-be President-elect on the impact of taxes on his blossoming plumbing business. The discussion was very specific—indeed, downright personal—and involved a calculation to the last dollar as Obama elaborated on how much Joe would pay in taxes under his plan as compared to John McCain’s plan.

Setting aside partisan policy issues, the point about this epic encounter is the manner in which the interest of a single person—albeit an archetype and icon—exploded into a metaphor of society. Joe the Plumber wanted to know what was good for him, not what was good for plumbers, his compadres in the building trades, the good citizens of Ohio, or anyone else in America, for that matter. In the case of Joe, the issue was taxes and, to Joe and many others, the optimal outcome in a world of personalized economics is to pay as few taxes as possible.

In the ebb and flow of dollars, personalized economics is at variance with personalized medicine and, because of dwindling money in the nation’s coffers, they are on a collision course. In the simplest form as promulgated by Joe, personalized economics involves giving as little money as possible to the government and possibly other cooperative instruments in society. Personalized medicine involves getting as much care as possible using all the bells and whistles of today’s technology. While rich people can perhaps afford the care inherent in personalized medicine, those less well off will have to rely on the help of others, whether from the government or insurers.

The election may be over, and controversy over the meaning of taxation may seem like a strange diversion. If, however, this country does not figure out how to spread the wealth around for healthcare—to balance the wants of Joe with the needs of the community—we are in for serious trouble, another of those Big Ones looming in America right now. In my next column, I will discuss further this difficult balancing act, especially as money for healthcare gets scarce.

Dr. Pisetsky is physician editor of The Rheumatologist and professor of medicine and immunology at Duke University Medical Center in Durham, N.C.