Friday, November 26, 2010

a joint affair.

Flashback to LU4. During our very first lecture in Rheumatology, the lecturer (the indefatigable Dr. Penserga) stepped up the podium and uttered her first sentence: A joint is an organ. Right away, there was a personal moment of epiphany. What I had previously believed to be a mere site of connection between two bones was, in fact, an active organ harboring a host of cells, cytokines, and everything in between.

Three years seems an awfully long time when one looks back at that definitive split-second and pauses to consider the potential array of knowledge (and yet to be discovered knowledge) that lay beyond the simple fabric of a joint capsule. Joints, as I later found out, only comprise a minute fraction of this exciting field. In rheumatology, it was always about recognizing patterns and asking oneself: “Could it be?” with surefire gusto and the confidence of an acrobat on a tightrope, hovering between a particular diagnosis and its really close mimic, never mind that one or the other appeared nothing like the classic textbook illustration. Dermatomyositis, polymyositis. Scleroderma, scleredema. (And you have overlap syndromes, too.) For the unwitting novice with the untrained eye, the difference could only stretch a little farther than a syllable – and the subtle signs that come with it.

Add that to the fact that the Philippines only has about 90+ rheumatologists wracking their brains off a plethora of syndromes and one rare disease after another. In my two week rotation alone, I was lucky to have seen both ends of the spectrum – from the almost symptom-free individual in remission to the barely conscious, intubated patient; from several cases of Behcet’s disease to Takayasu’s arteritis and polyarteritis nodosa – and smugly went home knowing something has piqued my intellectual curiosity and slaked my inner thirst for the unconventional and the unfamiliar.

Two weeks slowly gave me insight into the palpable difference between rheumatology and most other specialties. Rheumatologists seek not an ultimate cure but rather, an acceptable functional capacity and health-related quality of life for patients. And this is where tinkering with steroids and NSAIDS comes into the picture – the same old drugs with brand new tricks.

Even now we are already being ushered into the age of biologicals. Meeting IL-17 – the latest kid on the block – had been a real pleasure and so is trying my hand on the ultra-modern MSK UTZ. I thank all the consultants and fellows for a time well spent and for generously accommodating me into the world of inflammation and autoimmunity, where SLE and SSc are close cousins with everyone else. When all else fails, I guess there will always be your friendly neighborhood rheumatologist to help solve that rigged diagnostic dilemma.

Now I say: ankylosing spondylitis, anyone?

(Postscript: I eventually did my internship research on ankylosing spondylitis, which went on to win second place in the Annual Interns’ Research Forum for that year, got accepted for poster presentation in an international conference in Granada, Spain, and was eventually published in the Philippine Journal of Internal Medicine.)