E- ISSN: 2709-5533
Vol 5 / Ene - Jun [2024]
globalrheumpanlar.org
Columns
Trajectories
Autor: Alberto Palacios. Head of the Department of Immunology and Rheumatology at the Hospital de los Angeles Pedregal in CDMX
DOI: https://doi.org/10.46856/grp.22.et183
Cite: Palacios Boix A. Trajectories. Global Rheumatology. Vol 5/ Ene - Jun [2024] Available from: https://doi.org/10.46856/grp.22.e183
Received date: February 16th / 2024
Accepted date: March 12th / 2024
Published Date: March 21th / 2024
Forty years ago, I delved into Rheumatology formally for the first time. My rotation in that department at the INCMNSZ lasted three months, and I had to adjust with the other necessary rotations to undertake my subspecialty. I was in the third year of Internal Medicine Residency and thought my future was resolved. I was already a father of two children and had left their mother quite abandoned amidst shifts, publications, and now, additionally, thematic seminars that became the source of evaluation of my histrionic abilities alongside my knowledge base. The first of such challenges was a description of the rheumatic manifestations of diabetes mellitus, which was highly celebrated by my colleagues and, I dare say, paved the way for me to be accepted as a resident in the subspecialty a few months later.
I will not dwell further on this stage, except to have noticed, from the outset, that I could merge my interest in basic sciences applied to pathophysiology with a delight towards the affective processes that surround chronic illness. My boss at the time, Dr. Donato Alarcón Segovia, a notable mentor later in these same paths, dared to suggest that I should continue my studies at Wellesley Hospital in Toronto to unravel the intricacies of Fibromyalgia, a syndrome that had been described some time ago to the bewilderment of both insiders and outsiders. Despite his intuition, I declined to fully dedicate myself to Immunology, which in those years had debuted as an unknown field worthy of exploration to unveil the secrets of autoimmune inflammatory phenomena. I wasn't wrong, but the taste of a gap to investigate human suffering continued to dictate my interests. I would resume it three decades later.
I already had an offer then to continue delving into psychopathology, that is, to undertake studies abroad in Psychiatry, a promise that would not be fulfilled, primarily due to my reluctance to remain under my father's shadow. One can hardly discern what stumbling blocks the Oedipal path entails when it is not fully analyzed.
Be that as it may, as spring dawned, and after declining an invitation to pursue a Master's degree in Medical Education in the United States, I joined the Department of Immunology and Rheumatology driven by a good friend, Arnoldo Kraus, who would be my confidant and protector during that first year of fellowship, given the academic (and emotional) pressures that I managed to glimpse but did not fully anticipate. I must admit that it was a stage of deep confusion and high expectations, which tested my stability and intelligence.
Fortunately, facing head-on the pain and disability of rheumatic patients further united my interest in the emotional deterioration that accompanied such symptomatology. It was obvious that no deformity was not cloaked in profound mourning and that no physical pain was devoid of a tragic desolation or a loss of guarantees. Patients came to our offices in the old outpatient unit, next to the rear entrance of the hospital, to occupy the widest spaces, of course, given that most came in wheelchairs or accompanied by a retinue of family members who completed the clinical history with anecdotes and misfortunes.
There wasn't much to offer them, even more. Systemic steroids brought huge undesirable effects, gold salts were reserved for a few who could afford them or tolerate them (the sadly famous "chrysiases"), while D-penicillamine and hydroxychloroquine - which were already scarce - yielded results as slow as they were despairing. In short, we saw them gradually deform, become prey to complications, or, worse still, how our drugs, no matter how candidly we administered them, caused more harm than benefit.
Two important findings occurred alongside such a deficient therapeutic arsenal. The first of these was an encouragement and a quick disappointment. A colleague from previous years, Dr. Josefina Sauza, of Monterrey origin, had initiated a protocol with a drug called Benoxaprofen that yielded surprising results in patients with rheumatoid arthritis. I took over the cases that were still under phase three surveillance, and it was noticeable how well their disease had remitted, something unusual in those years. Unfortunately, various reports of hepatotoxicity of the drug in question appeared, and it was immediately withdrawn along with our hope and the well-being of the thirteen patients who had received it. Returning to conventional treatment was a disappointment for everyone.
The second was the observation that methotrexate, an antineoplastic drug used in leukemia and some solid tumors, could reduce the activity of lymphocytes incited to penetrate inflamed joints when used at low weekly doses. This information, which would take a few more years to become generalized worldwide, was decisive for the treatment of inflammatory arthropathies. It soon extended to psoriatic arthritis and spondyloarthropathies with unprecedented success. I must add that at first, we even performed liver biopsies on patients who developed minimal hepatotoxicity, fearing repeating the Benoxaprofen scandal. The original study we discovered - like children opening Christmas gifts - Kraus and I in Seminars in Arthritis and Rheumatism in the fall of 1983, and we immediately began to apply it. Rarely in my fledgling academic career had I felt like conquering a new world, and I think such occasions have been few since then.
Even upon my arrival in the United Kingdom to do a post-doc in Rheumatology, there was widespread reluctance to use methotrexate. Four years later, upon my return to Mexico, all the doctors I met during that stay were using it, and both gold salts and D-penicillamine were falling into disuse.
My return also included the first hints of "Biological Therapy" with the discovery that inhibition of tumor necrosis factor was much more effective in murine models than oral tolerance or manipulation of type II collagen.
However, despite these advances in the therapeutic field and the contribution of epidemiology to seek better methods of evaluating the benefit and prognosis of rheumatic patients, affective symptoms and depression still reigned in my consultation. There was not a day when a patient did not complain of abandonment by their partner, dismissal from their job, difficulty in having sexual relations, abuse of their children, or the irremediable deterioration of their economic situation. Each of these outcomes affected their daily perspective and life expectancy in the face of our growing impotence.
It would be naive to assume that as a doctor, one can do much more than listen and encourage, hence the importance of contributing with my experience and certain practical techniques to improve the quality of life and therapeutic adherence of patients with chronic illnesses.
In this sense, the decades I have traversed have taught me greater humility and better quality of listening, resulting in emotional support in the face of pain and moderation in the use of anti-inflammatories and biological drugs. While immunosuppression has been the therapeutic substrate for autoimmune phenomena, as is obvious, its excess leads to catastrophic results and undesirable effects that make the path more daunting.
But certainly, it was necessary to round off the clinical experience with a more analytical view of the narrative that encompasses every affliction.
Nineteen years ago, after confirming my father's surprise, I decided to study psychotherapy. My lack of formal training in mental illnesses brought me into contact with Pavilion 9 of Psychiatry at the Spanish Hospital, under the direction of Dr. Carlos Serrano, with whom (in addition to his peers and residents) I will be grateful for life.
Over the next five years, I learned to delve into and reinterpret mental processes like never before, from Sigmund Freud and Donald Winnicott to Mark Solms, Christopher Bollas, Laurent Assoun, André Green, and many other brilliant contemporary psychoanalysts.
My unconscious, and why not, Oedipal rivalry, meant that I did not complete the desired training, but it brought me the greatest happiness of my existence in two daughters who illuminate my path every day.
Today, more resolved and aged, I can dedicate special attention to my patients, perceive their internal cries, shelter their wounds, and, without pretenses, accompany them toward a more prosperous future in the arduous journey of illness and pain. Perhaps such an exercise is a concert, epiphany, and odyssey in one endeavor.
