In early spring this year, as daffodils erupted throughout Durham, N.C., and tears streamed after basketball defeats, I had the good fortune of spending an hour in enjoyable conversation with a group of academic rheumatologists. We were on our way to the airport after a stimulating and challenging meeting on lupus. Instead of one of those bumpy and creaky 20-seater buses, we were in back of a stretch limo, a Lincoln Navigator supreme, a vehicle ideal for parties and proms, an extravaganza of sheet metal that was as long as a train and that glistened obsidian black.
The seats that lined the limo interior were cushy, covered by tan leather that had softened and faded. The floor had maroon-red carpet that thankfully smelled of carpet cleaner instead of something more alcoholic or intestinal, as would be expected given the usual limo riders and their exuberant, inebriated celebrations. Although the limo had a rack of champagne glasses, alas, there was no bubbly. I told one of my companions on this trip, a distinguished personage in rheumatology—let us call him Dr. D.—that the limo service must have thought that he was a rap star and we were his posse. Otherwise, our transportation would have been more modest.
Of course, there will be issues of cost to consider, and the approach of insurers is unknown. Only time will tell about belimumab but, hopefully, it will become a valuable part of the treatment armamentarium, with its approval encouraging other companies to test new products for both renal and nonrenal manifestations. Despite many studies on lupus nephritis, there is no approved therapy for this indication. Trials for new products for renal lupus are likely to be a real bear for a disease named for a wolf.
As a disease, lupus can be menacing, even treacherous. The analogy with a wolf is apt since, at its worst, lupus can be a predator that snatches away young people. Not surprisingly, clinicians who specialize in this condition have dispositions that may differ from that of the average rheumatologist who handles more chronic and indolent diseases. Lupus investigators are a passionate and often strong-willed lot. Meetings on lupus can be intense occasions, filled with opinion, argument, and contention. They are definitely more exhausting than meetings on other diseases.
Research on lupus is full of controversy. What is the right way to treat nephritis? Is anti-DNA a reliable biomarker? Is estrogen replacement safe? Acronyms for disease activity proliferate, and people fight over the nuances in counting disease manifestations and the validity of including serology or patient reports in generating a score for current activity. Is the SLEDAI better than ECLAM or RIFLE? And when one of these indices is named SLAM, you know that these people are tough and mean business.
“Rheuminations” Answer
In addition to belimumab, the other FDA-approved drugs for lupus are:
- Aspirin
- Hydroxychloroquine sulfate
- Prednisolone
- Triamcinolone hexacetonide (discoid lupus)
Sharing Secrets
On the way to the airport in our shiny boat of a conveyance, we drove along a wide suburban highway surrounded by big box stores and every fast-food restaurant in the world—McDonald’s, Jack in the Box, Taco Bell, and more. A panorama of logos enticed us to exit the thoroughfare and dine on meals that, in a single sitting, would provide enough salt to fill the extracellular space of the average person with sodium for a week or two. No such indulgence for us. The meeting organizers had thoughtfully provided us with healthy box lunches that even contained an apple each.
Traffic slowed and snarled, as is inevitable in that area of the world. With the Scylla and Charybdis of lupus trial design behind us, we exchanged the usual gossip about the comings and goings in academia. We then moved onto personal subjects, including the lifestyles of today’s academicians and the struggle to balance the demands of work and family. In that vein, Dr. D. described a retreat that he had had with his division’s faculty. At this retreat, each faculty member was asked to tell the group something about himself or herself about which the others were likely unaware. Dr. D. relayed how interesting this activity was as the group heard about the “secret” lives of their colleagues, including hobbies, avocations, and travels. At the top of the list were remnants of past history that simply do not come up in conversation.
Even at their wildest, physicians are a pretty staid lot, and any secrets that are hidden are not likely to be all that shocking. Many of the secrets are actually an achievement in another realm, like being the chess champion of Baltimore or the glockenspiel player in all-state band in Wisconsin. Nevertheless, I am always amazed by how much personal history is forgotten or erased once a person starts a career as a physician. Medical training is a powerful homogenizer of people—a veritable Waring blender of personality—to emulsify and pulverize any chunks of real individuality that may persist in the face of a curriculum that can be genuinely deadening. By the end of an education that can extend over a decade, trainees have a remarkable sameness, whatever their place of origin, family background, or prior pursuits.
Over the years, I have discovered that, among the medical students, house officers and fellows with whom I worked, I trained people who had prior lives as a ballet dancer, public health nurse, Army medic, opera singer, particle physicist, professional rock climber, desk clerk at a YMCA, oil engineer, drug representative, veterinarian, lawyer, and commander of a nuclear submarine. Not a speck of these remarkable life journeys showed in the work of these people, however, since all behaved virtually identically on the ward or in the clinic. I gleaned this information mostly by accident or inquiring why my medical student was 40 and had two children in high school.
Of this group, I especially liked the lessons I learned from the submariner. He had a sharp, precise manner—actually, he was a bit tightly wound—and was perpetually exasperated by the generally haphazard way we organized the ward work, bristling and fuming over our tardiness on rounds. When I asked him how to run things better, he said dryly, “Simple. Post a duty roster.” I had to suppress my laugh; the notion of a duty roster on a teaching service is downright ludicrous. With a straight face, I asked, “And if that doesn’t work?” “Take away shore leave,” he said with surprisingly seriousness, his eyes tough and steely, befitting a person who could give the command to launch a nuclear strike.
Connect the Past with the Present
As we wended our way to the airport, traffic came to a standstill, and my good friend Dr. D. turned to one of the woman rheumatologists in the limo—an up-and-coming clinical investigator whose age is probably less than 40—who was a member of his division. Let us call her Dr. M. With a bit of mischief in his eyes, Dr. D. asked, “Do you want to tell us about yourself?” Dr. M. smiled and made a small wave of her hand to signify her demurral.
“Come on,” Dr. D. persisted, looking at his colleague. “It’s not bad.”
Secrets are always problematic because, even if trivial, their hidden nature cries for discovery, an effort to crack the code or lift away the rock from the dark and mysterious overgrowth covering a path to the past.
My mind began to spin about the possibilities for Dr. M.’s secret, although figuring out what she had done in the past was not all that difficult. One look at her would give the answer. Dear readers, we have a matter of some caution and delicateness here since any description of this woman that I would provide could be subject to misinterpretation, implying that I was paying undue attention to her appearance or, egads, noticing her body. Friends, I am a doctor. I am allowed, encouraged, and required to look at people’s bodies. It is a habit that is hard to break or segregate into work hours. I am also a writer, and writers have to describe the people in their chronicles.
Suffice it to say, Dr. M. appeared in no acute distress, looked younger than her stated age, and her head was normocephalic and atraumatic. By inspection, there were no obvious deformities of the extremities and, when I had observed her walking to the microphone to ask a question at the meeting, it appeared that her strength and gait were intact. I could say that she moved with agility and grace, with a quick, sprightly, and decisive step. If I said that she was lithe or lissome, I would probably get in trouble. (As a disclaimer, lithe and lissome were not my idea. They came from the thesaurus. Shift F7 made me do it.)
No doubt, Dr. M. had once been an athlete of some kind, although given the context of the discussion—the idea that past athletic accomplishment was worthy of secrecy—I could not help but wonder about something more unconventional, colorful, or exotic: a runway model, a stunt woman, or a dancer at the Tenderloin.
Or maybe Dr. M. was the girlfriend of a mobster who had turned state’s evidence, conveniently and cleverly stashed by the FBI in a witness protection program and assigned to a new identity—academic rheumatologist! Trust me, no mobster on the lookout for a stool pigeon would expect to find his quarry hiding in a rheumatology clinic filling out the Systemic Lupus International Collaborating Clinics damage index. She would have been assured years of safety in such an employ.
A Truth Less Strange than Fiction
As it turns out, Dr. M.’s secret past was no big deal and, with a little prodding from Dr. D., she told us her story. As a teen, she had been a top junior tennis player, ranked in the top 10 in her state. During one tournament, her opponent had been someone who became a big-time player whose name once filled the sports pages. Alas, Dr. M. suffered defeat at the hands of the future pro, a baseline basher with bruising groundstrokes.
As we all know, our society accords special status and recognition to its athletes. After all, they are called heroes and treated as royalty, as if pitching a fast ball or hitting a jump shot represents greater genius or a bigger gift from the gods than the myriad other activities which supposedly lesser mortals pursue. Those activities demand as much practice, tenaciousness, and spirit, although they are usually pursued with anonymity and sometimes paltry remuneration. Such activities, I may add, include taking care of sick people with lupus as well as conducting basic, clinical, and translational research.
Nevertheless, I could not help but be impressed by Dr. M.’s past. The ethos of sports has been etched into me since I was child. I grew up sitting in the stands at Yankee Stadium to see Mickey Mantle blast homers into the upper deck, watching former basketball players Bob Cousy and Bill Russell on TV winning championships in the smoke-filled Boston Garden, and listening on the radio to the Muhammad Ali fight against Sonny Liston, the announcer shrieking at the early knockout. I cannot help but accept society’s judgment that athletes are special people who should be exalted.
Although Dr. M. had a very promising tennis career—top 10 in the state is not exactly chopped liver—she decided that there was more to life than chasing yellow balls on the hard court and blasting them back with a powerful whack. Dr. M. put away her racket, perhaps in the dark confines of her bedroom closet or amidst garden supplies and old bicycles in the garage. She then went to medical school and is working her way steadily up the academic ladder.
Knowing Dr. M.’s scholarship and research on new treatments for lupus, I am very glad that she became a rheumatologist instead a tennis pro at the local club, the kind of person who has scars on shoulders and knees from surgeries to fix rips and tears, skin turned leathery in the sun, and long days spent teaching 10-year-olds how to hit the ball with more spin.
Dr. M. was modest about her athletic accomplishments and graciously said that, if we attend another lupus meeting together, I should bring my racket so that we can volley a bit or even play a few games. Given my current shape, any record of our match would more likely show up on “America’s Funniest Home Videos” than ESPN.
So, to my fellow limo rider with a storied hard-court past, thank you for telling us about your exploits as an athlete. I looked you up on PubMed and think that you are certainly in the top 10 in a state filled with some of the best lupologists in the world. You are making fine progress. Be aware that the rewards of sports and medicine are different. In our profession, there are no autograph seekers or paparazzi, no dopey interviews with the media (“Tell us, Dr. M., what was going through your mind when you presented the data on safety?”), no appearance money, and no endorsement contracts from Avon, Reebok, or Gatorade—the Williams sisters and Maria Sharapova (who is lithe and lissome, by the way) have that business sewn up.
As you continue to do research and advance in your academic career, Dr. M., please use the lessons you learned playing tennis: Work hard, keep your eye on the ball, and follow through.
Good luck. And, for the patients with lupus who need your help, I hope that you hit real winners.
Dr. Pisetsky is physician editor of The Rheumatologist and professor of medicine and immunology at Duke University Medical Center in Durham, N.C.
