ESSAY - The Joint Man Returns

[Guest guest]

The following essay, courtesy Rheumawire, " The Joint Man Returns, " is

written by rheumatologist Dr. S. Pisetsky. He's a wonderful writer

and, most likely, physician. A few years ago, I was deeply moved by his

" Praying for Golden Raisins " which appeared in Arthritis Today.

Nov 17, 2004

Dr. S. Pisetsky

The Joint Man Returns

When I started my career in rheumatology in 1978, the fellows and

attendings all carried a rubber stamp called the " the joint man. " The

" joint man " was a homunculus and, like all good homunculi, was a

horribly distorted depiction of the human body. We would stamp the

" joint man " on consult sheets and progress notes to visibly record the

joint counts of patients with RA.

The " joint man " was just about all hands and feet, with a circle at the

place for each joint. The head had two little circles for the

temporomandibular joints, but the chest and abdomen, the usual focus for

internists, were just a straight line. If a joint was tender, an " X " was

placed. If it was swollen, the circle was filled in. Sadly, in 1978,

many " joint men " were clusters of blackened circles with Xs, a stark

demonstration of RA's menace.

In that era, the rheumatology quiver did not contain many arrows. Beyond

NSAIDs, there was the dreaded prednisone. Prednisone gave relief but it

withered people and made their skin look like paper. As one of my

colleagues said, " Prednisone is a bad drug. It is easy to start and hard

to stop, " There was also gold, a drug of suspect efficacy and

frightening toxicity. Plaquenil lurked in the shadows, no one quite sure

that a drug designed for malaria could actually stop arthritis.

Eventually, methotrexate came along. From the beginning, it was clear

that methotrexate was a winner, a drug that truly worked. Joint counts

plunged, and the " joint man " became a relic as aggressive therapy began

its vogue. If a patient complained of swelling and pain in a joint or

two, out came the methotrexate. Why wait until a double-digit joint

count to pull the DMARD trigger?

In most things medical, I am old fashioned. For years, I have missed the

" joint man. " Clearly, he was too low-tech to survive, no match for Sharp

scores or the nifty images of an MRI. With the advance of better drugs

and new technology, formal joint men vanished along with 50-foot walk

times and tests of grip strength with the cuff of a sphygmomanometer.

In medicine, as in all endeavors, there is no free lunch, and with

progress in RA treatment, costs have boomed along with efficacy. As each

new drug hits the market, insurers and health-system bureaucrats wail

about expenses and conjure ways to curtail use. Against my better

judgment, I am now part of that system. Among my jobs as an attending in

clinic, I have to sign off on all prescriptions written by our fellows

for TNF blockers. My seal of approval is supposed to ensure that use is

" appropriate. " Trust me, while a pain, this job is a lot better than the

one I had approving coxibs.

Let's not debate the ethics or wisdom of gatekeepers but, even in this

role, I don't like to be a slacker. So, when fellows ask approvals for

biologics, I do my job. I interrogate them intensively, challenge them

now and again, and ask for numbers, not impressions, when a big price

tag is in the offing. Hence, I have resurrected the " joint man. "

The principal is the same, but the " joint man " now operates in the guise

of the disease activity score (DAS). To the " joint man, " the DAS adds a

erythrocyte sedimentation rate (ESR) and global assessment score and

crunches numbers with a formula worthy of quantum mechanics. As the

arbiter of expensive meds, I have decreed that anyone considered for a

TNF blocker needs a DAS.

I am happy to have my little friend, the " joint man, " back. Actually, I

think that his presence makes my fellows better doctors. They are more

attentive and compulsive in their physical exams and inquire more deeply

about their patients' lives. I thrill as they carefully assess the

joints, all 28 or 44 of them. To make the fellows' job easier, I have

given each of them a DAS calculator, thanks to a drug company's

largesse.

The other day, one of the second-year fellows called me to see a patient

she wanted to put on a TNF blocker. She said the man was miserable,

resistant to methotrexate, sulfasalazine, and leflunomide and surviving

only by dint of prednisone in ever-escalating amounts. She said the

man's joints were hot to the touch and that his AM stiffness had

stretched into a PM affliction.

The decision was a no-brainer. Nevertheless, I asked, " What is the DAS? "

The fellow looked querulous, her eyes uncertain behind her glasses, " Do

I really need a DAS for a patient like that? "

" Absolutely, " I said solemnly. " The therapy you are starting is very

expensive and can be dangerous. Do you want to give a drug that can lead

to tuberculosis, heart failure, and lymphoma unless there is good

reason? We're talking $10 000 a year here. Don't you think that merits

more documentation? You must do a joint count and calculate the DAS. "

She hurried off as I relaxed in the doctors' workroom in the clinic. The

walls of the workroom are a faded green but sun streamed in that day and

made the room look bright.

A few minutes later, the fellow came back beaming. " The DAS is 4.90, "

she said, excited and relieved.

I went to see the patient and actually found 2 more tender joints than

the fellow did. Satisfied by such a towering DAS, I took out my

prescription blank and scribbled down the magic.

" In some countries in Europe, you need a DAS of 5.5 before you get a TNF

blocker, " I added, trying to show how truly reasonable I was being. The

gate I guard is really easy to open.

My clinic peaks at about 11 AM, the hour a siren sounds each day to test

the hospital's emergency system. Usually, after that, the patient volume

ebbs, and I have time to read a journal article, log on to UpToDate.com,

or search the web. That day, for fun, I decided to do an experiment.

Having become an enthusiast of the DAS, I decided to calculate my own

score and see how I match up with the patients.

The doctors' workroom is near the patient waiting area and I could hear

laughter and sounds of the TV. Not wanting to be seen examining myself,

I closed the door. I took off my white coat, sat on the side of the

desk, and proceeded to do a joint exam.

Not surprisingly, none of my joints was swollen, but the proximal

interphalangeal joint on my left little finger was quite tender. It is

the result of an injury I sustained teaching my daughter to play

basketball. She was 6 or 7 at the time. In the backyard court, she threw

the ball up with great force, except it hit the rim and careered toward

my face. Reflexively, I put my hand up as I closed my eyes. The ball hit

my finger straight on. I felt a jolt of pain and, when I opened my eyes,

the top of my finger was at a 90-degree angle.

I popped my finger back in place as sweat poured from my brow and my

vagus nerve went firing.

" Are you OK, Daddy? " my daughter asked sweetly as I collapsed under the

basket.

" Just resting, Sweetie, " I said as nausea spread through my prostrate

body.

I recovered but I am sure that there is degenerative joint disease at

that beleaguered spot.

During my exam, I also found a tender right Achilles tendon, another

sports injury, as well as 5 bona fide tender points. Stress or not

enough sleep, I said to myself, wondering whether I was being stricken

by the F word.

My joint exam finished, I pulled out my DAS calculator to tally the

score. I punched in 1 tender joint and 0 swollen joints and gave myself

an ESR of 20. I assumed that my acute-phase reactants were resting

quietly in my liver and were not on the prowl.

It was when I got to the global assessment that things got shaky.

I am 58 and in good health, but in my heart of hearts, my global

assessment is not 100%. Alas, it is less.

Things don't work so well any more. I have gained weight. My waist has

grown relentlessly and my tailor has leveled with me that there is no

more cloth to let out of my favorite Zanella pants. My eyes are

weakening, and I constantly lose the magnification glasses I buy at

Costco.

I used to be a runner, the veteran of 2 marathons. My regular run is now

only 2 miles but sometimes I get tired and mix walking with jogging.

When I was training for my first marathon in 1983, I once felt so good

after an 18 miler that I added an extra 2 miles to reach an even 20. My

running output has fallen by an order of magnitude.

My global assessment is not 100% or 90%. It is 80% at best, but, to tell

the truth, I think I would call it 70%.

Why so low? Well, recently, I was in Boston at a meeting and stayed in

Cambridge, where I went to college. In college, I was in great shape and

ran hundreds of miles and competed in rowing. I got to my hotel, put on

my running clothes, and went over to the college track for a workout.

It was near dusk on a November evening and a silvery moon was shining

low in the blue-black sky. The traffic rumbled as I ran by the campus,

passing the darkened facade of the football stadium along the way. At

the track, a cold wind blew across the infield. The women's team was

still practicing.

Watching the women glide around the track, I felt an urge to compete and

decided to do something I hadn't done in more than 10 years: time myself

for a 400-m run. I was never was a speedster but I was competent and had

endurance and, training for the marathon at the age of 42, would do

strings of 400s at under 80 seconds.

I waited until one of the slower women came by, took a deep breath, and

pushed the button on my little nerd watch and started running when the

woman reached me. I left a polite distance between us so as not to

appear a stalker.

After the first 150 yards, the distance between us grew as my breathing

quickened. I felt a pain in my side and my quads began to ache. The

woman was now 50 yards ahead of me. I picked up the pace and felt I was

closing the gap.

As I rounded the last turn, I was breathing with almost every step and I

was beginning to sweat in the cool night air. I strained as I started

down the last straightway. The woman was nearing the finish line as I

put on all the speed I could muster. My lungs burned as I sprinted the

last 50 yards, pushing the stop button on my watch as soon as I crossed

the line.

The race over, I felt drained and, coughing and spitting, bent over to

catch my breath. With so much exertion, I was sure that my time would be

impressive.

In late fall, darkness descends quickly in Boston and, without my

glasses, I couldn't read the numbers on my watch. I walked over to a

lamp at the side of the track and, squinting, looked at the display. In

disbelief, I saw my time.

That evening, my time for a single 400-m run flat out was at the same

pace at which I ran entire 10Ks in my prime. I was shocked, wondering

whether my watch was broken. I fiddled with the buttons, and it was

clear that it was me and not the watch that was on the fritz.

I walked a lap in the outside lane, trying to settle down as the women

runners zipped past me. Hoping I could drop my time to something more

respectable, I decided to run another 400 but, soon after I started, I

pulled my hamstring. Wounded, I trudged back to the hotel.

Thinking of that moment, I know why I rated my global as 70%. I'm

getting old.

In the DAS score, the numbers for global assessment are reversed, so I

punched in 30%. With another button push, the calculator gave the

verdict. My DAS was 3.08

A DAS of 3.08 is in the yellow-green region, a smidgen below the cut-off

for active disease. If I had RA, I would be on the launching pad for

real meds.

My DAS score was, of course, bogus, skewed by a global assessment

totally lacking sense and assessed in humility. If my concocted DAS was

a 3, I realized that a DAS of 5 or 6 must be terrible. At 5 or 6, the

whole hand is as tender as my pinkie when it was thumped by the

basketball, and an elevated global assessment means trouble walking, not

pokiness on the track.

I heard a knock on the door. I opened it and one of the other fellows

came in to ask about a prescription for a TNF blocker.

" The DAS is 5.67, " he said assuredly, showing me the calculator to

hammer home the point.

" I'll double check, " I replied meekly.

As I walked down the hall to the see the patient, I was distracted and

almost bumped into a frail man leaning on his cane.

Thinking about my own DAS, I asked myself whether it would it be worth

$10 000 a year to get my global assessment back to 100%. At 100%, I

could run for hours on end and charge up hills for a lark. At 100%, I

could row miles in the summer heat and power my boat with a flawless

stroke. At 100%, my belly would be firm and flat and my eyes would see

the tiniest print.

For that 100%, I would stick needles into myself every day, risk TB,

and, if some hard heart would not spring for a measly 10 grand, I would

sell the Saab and take a second mortgage.

Thankfully, I do not have arthritis. I have just a little age on me and

some wear and tear but, in thinking about what I would do to get back to

100%, I can only imagine what patients with RA feel like to have a drug

that can relieve their pain and revive them as people.

My experiment with the DAS may have been contrived, but I discovered

what should always been apparent: the " joint man " speaks and, to be a

better doctor, you should open your mind and learn how to listen.

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org