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From: The Rheumatologist, October 2011

It's All About the Patient

Trailblazer Evelyn V. Hess combines science and patient care

by Gretchen Henkel

We always knew she was going a thousand miles an hour,” recalls Kenneth Grant, MD, professor of medicine at Touro University in Nevada, of his former mentor Evelyn V. Hess, MD, distinguished professor emerita and founder and former chief of the division of immunology, allergy, and rheumatology at the University of Cincinnati Medical School. Adds Michael Luggen, MD, another former fellow of Dr. Hess and professor of clinical medicine in the Division at the University of Cincinnati: “She had boundless energy. She accomplished so much that I kind of wondered if she ever slept!”

Starting and building the first division of immunology, allergy, and rheumatology at the University of Cincinnati Medical School comprises only one aspect of Dr. Hess’ remarkable career. Indeed, a reading of her curriculum vitae reveals her intense involvement in research (more than 152 scientific papers, 73 book chapters and reviews, and 205 published abstracts), in professional societies (both national and international), in patient advocate organizations, in governmental affairs, and civic activism. Born in Ireland and completing her medical training in London, Dr. Hess came to the United States in 1960. In her words, she never returned to live in “good old England,” but their loss became our gain. She has made an indelible imprint on the fields of lupus research and patient advocacy, and in the careers of more than 80 rheumatology fellows whom she trained at Cincinnati.

The Attraction to Medicine

By the age of 15, Evelyn V. Hess had already determined that she wanted to be a doctor. This was a remarkable choice in the 1940s, when few young women were taking that road. She didn’t have a physician role model in her family, but several childhood experiences contributed to her fascination with medicine. As a young girl, she had witnessed a friend’s death and ministered to a classmate who had epilepsy. And, she recalls, “My best friend’s father was a physician. We were often in their house, and whenever I possibly could, I would take down all the medical books and read away until darkness fell.”

After obtaining her undergraduate medical degree at the University College in Dublin, Dr. Hess began her medical training in London. While a registrar in internal medicine and pulmonary disease at the Royal Free Hospital Medical School in London, she was also exposed to rheumatology. The fact that these diseases affected almost every part of the body intrigued her. “There didn’t seem to be too many people who were working with or for the patients,” she adds. That theme—working with and for the patient—has been her life’s calling and a binding thread throughout her career.

In the late 1950s, she applied for and received a traveling fellowship from the Empire Rheumatism Council to continue her training in the United States with Morris Ziff, PhD, MD, of New York University in New York City. On the eve of her departure, Dr. Hess recalls, she received a telegram from her soon-to-be mentor: “If you want to work with me, you’d better come to Texas.” Dr. Ziff had just accepted a position with the University of Texas Southwestern Medical School in Dallas. Dr. Hess jokingly adds, “I wasn’t even sure where Texas was! But it turned out to be a terrific unit in the medical school, and I was very pleased.” She published a number of papers in concert with Dr. Ziff and other colleagues on autoimmune nephrosis in the rat and heart muscle antibodies in rheumatic fever, and was on the fast track to a successful academic career.1-3

In 1965, she was recruited to Cincinnati and shortly thereafter established the division of immunology [as it was first called] in the department of medicine. An intense period of growth and activity followed. Not only was she directing the division, overseeing the lab and training fellows, she continued investigations focusing on the effects of drugs on cartilage metabolism, and later moved into drug-related models in systemic lupus erythematosus and the role of endothelial cells in rheumatic diseases.

It seemed that Dr. Hess was committed to all aspects of rheumatic disease. She worked tirelessly for the advancement of the field, serving on American Rheumatism Association (ARA; now the ACR) and later ACR committees. She was one of the founding members, along with its originator James Fries, MD, of the American Rheumatism Medical Information System (ARAMIS) and remained on its steering committee for more than three decades. She was also instrumental in passing the Ohio Arthritis Act, which specifically funded patient education and supported fellowship training statewide.

A Thriving Division

According to many of her former fellows, Dr. Hess possesses an uncanny knack for steering the careers of those she trained. “She had high expectations for each and every one of us,” says Dr. Luggen, “and attempted to motivate us to be the best that we could be. She asked difficult questions and expected us to know the answer—or to find it quickly.”

George Spencer-Green, MD, senior director at Vertex Pharmaceuticals in Cambridge, Mass. and former director of the rheumatology section of the Dartmouth-Hitchcock Medical Center, describes Dr. Hess as a “take-charge” leader who built a division of “very colorful and bright people” who have gone on to make their own mark in basic and clinical research, as well as drug development.

“Shortly after I joined the faculty in her division,” Dr. Luggen recalls, “she told me that I was going to be co-director of the Cincinnati site of the Cooperative Systematic Studies in the Rheumatic Diseases.” At the time, Dr. Luggen had very little background in or knowledge of clinical investigation. “She felt that that’s where I should go—and there was usually no point in resisting! I think we resisted less than we might have because we had this suspicion that she was right, and that, if we did what she asked, it would benefit us more than we could know.”

The co-directorship united Dr. Luggen with many influential and innovative investigators, such as Hal Paulus, John Ward, and Jim Williams. He now reflects, “It was a wonderful learning experience that enabled me to make contacts I would not otherwise have been able to make. To this day, my primary research interest is the design and execution of clinical trials.”

A Tough and Proactive Leader

“You always felt that you needed to be respectful of her,” notes Dr. Grant. “But after she got to know you and like you, she was very kind and always tried to give to us. Tickets to the opera house or a hockey game would somehow wind up on your desk, and you didn’t know what you had done to possibly deserve that!”

Ram Raj Singh, MD, professor of medicine, pathology, and laboratory medicine at the University of California, Los Angeles was also the recipient of Dr. Hess’ generosity. As a team leader, he says, she had real warmth for the other people in the group. “When people did good work, she would go out of her way to show her appreciation. There wasn’t a week that I did not receive something from her in my mailbox: either a paper from Science or another journal related to lupus, or a ticket to the Reds game.”

Dr. Spencer-Green agrees: “She was very generous in many ways and would always share what she could.” He recalls that Dr. Hess first sought him out after he presented a paper at the ARA’s annual meeting in 1975. At the time, Dr. Spencer-Green was an intern on the general medical house staff at the University of Cincinnati. His medical school mentor had submitted his research project in rheumatology. Dr. Hess sought him out and recruited him to join her fellowship program. When he completed his fellowship, Dr. Hess helped him obtain a postdoctoral grant from the National Institutes of Health (NIH), get an appointment in the department of pathology and laboratory medicine, an appointment in the department of medicine, and a position as chief of immunology at the Cincinnati VA Medical Center. Dr. Spencer-Green was also the first fellow to receive training support through the Ohio Arthritis Act, which Dr. Hess had been instrumental in establishing.

“She was the kind of person,” he says, “who would go to bat for you, work behind the scenes, and find ways help you any way she could. She was proactive and made it her business to look for opportunities and make those available to you.”

Dr. Hess in her laboratory.
Dr. Hess in her laboratory.

An Astute Observer

Matthew H. Liang, MD, MPH, professor of medicine at Harvard Medical School; professor of health policy and management at Harvard School of Public Health, Brigham and Women’s Hospital; and study director at VA Cooperative Studies Program, all in Boston, first met Dr. Hess at an NIH site visit to the Brigham program. He recalls her as “a stately and dignified person, who made me feel that my research was worthwhile.” On the site visit, she observed to the group, “Oh, you’re doing social rheumatology.” This characterization of his work stuck with him, says Dr. Liang, helping to validate his investigations. “She was one of those senior people in rheumatology who had the vision to put a ‘name’ to our work and appreciate that, even though it was not conventional, it was important. It made a big, big difference.”

Patients First

Dr. Hess’ dedication to patient concerns drove her tireless enthusiasm for lupus research, Dr. Singh believes. Her work on the environmental aspects of lupus beginning over 30 years ago advanced the thinking in this area, he notes.4 Dr. Singh, who has published several papers on hydrocarbon oil-induced lupus in mice, cites her work often. Yolanda Farhey, MD, professor of clinical medicine in the division of immunology and rheumatology at the University of Cincinnati, says, “Not only was Dr. Hess interested in the environmental factors in lupus, but she opened our minds to the idea. Both of us have a fond spot for these subjects, and have been collaborators and also friends.”

The Rheumatologist asked Dr. Hess about the initial reception from colleagues when she first began positing the theory of environmental factors. “In the beginning, people said, ‘Oh well, I’m sure these diseases have nothing to do with the environment.’ ” She quipps, “But at least they didn’t shoot me! Then more and more people became interested [in this line of investigation] and environmental factors became a whole section in the rheumatic diseases.” Dr. Hess participated in the ARA’s Industry Committee and was one of the authors of a consensus paper, “Approaches for identifying and defining environmentally associated rheumatic disorders.”5

Leslie Hanrahan, vice president of education and research at The Lupus Foundation of America (LFA), credits Dr. Hess’ research with helping to put lupus on the map. Recognizing Dr. Hess’ contributions to advance lupus research, the LFA in 2005 established the Evelyn V. Hess MD, MACP, MACR Award, presented at the ACR annual meeting each year to a clinical or basic researcher whose body of work has advanced the pathophysiology, etiology, epidemiology, diagnosis, or treatment of lupus. As a testament to Dr. Hess’ stature in the field, the number of nominations has grown in just six years, notes Hanrahan.

Putting patients first also involved, for Dr. Hess, an approach to patient examination which has almost become “a lost art,” according to Dr. Luggen. “What I carry from those years that I trained with her,” says Dr. Farhey, “is never to take for granted what other people may say about a case. Every single time you see a patient, see that patient with new eyes, and you’re bound to find something new. Whenever I did this, I was never disappointed.”

Left to right: Bill Mulvihill, athletic director at the University of Cincinnati and former Arthritis Foundation president, Mrs. Mulvihill, Dr. Hess, and Fred Finkelman, MD, McDonald Professor of Medicine and professor of pediatrics, Division of Immunology, Allergy and Rheumatology, University of Cincinnati.
Left to right: Bill Mulvihill, athletic director at the University of Cincinnati and former Arthritis Foundation president, Mrs. Mulvihill, Dr. Hess, and Fred Finkelman, MD, McDonald Professor of Medicine and professor of pediatrics, Division of Immunology, Allergy and Rheumatology, University of Cincinnati.

Dr. Hess has always believed in the importance of people with lupus being involved in their care. She carried that belief into action, becoming a charter member of both LFA and Arthritis Foundation. She still attends LFA board meetings. “For her,” says Hanrahan, “it’s all about the patient.”

The awards and accolades for Dr. Hess’ achievements have been numerous. She was named one of the Cincinnati Enquirer’s 1999 Women of the Year, received a Pan American League of Associations of Rheumatology Gold Medal in 2010, and received a Leadership Award from the Greater Cincinnati AIDS Task Force in 1991, having stepped up to the plate with HIV/AIDS patients ahead of many of her peers.

Dr. Hess received the American College of Physicians (ACP) Master Teacher Award in 1995, and in 2007, the ACP began awarding the Evelyn V. Hess Master Teacher Award to other young physician teachers. Dr. Hess remarks that she always enjoys teaching. “It’s good to be able to survive fellows,” she jokes. “And none of them went to jail!” On a more serious note, she reflected, “We need new generations of clinician–researchers now more than ever, because the rheumatic diseases have turned out to be quite complicated. You’ve really got to be an expert in immunology, rheumatology, and everything else. So we need young people who want to take the challenge.”

Hanrahan reflects, “I’ve always gotten the feeling that she was one of those people who thought that nothing was impossible. None of these autoimmune diseases are straightforward. All of them continue to be a challenge, and I think she likes that.”

On the occasion of receiving the University of Cincinnati College of Medicine Daniel Drake Award in 2001, Dr. Hess noted that she had gained great satisfaction working with patient-advocacy volunteer organizations, such as the Arthritis Foundation, the LFA, and the Cincinnati AIDS Task Force, among others. “In this way,” she said, “one has the best of both worlds, combining science and patient care.”

Timeline

1949 – Earns MD from University College, Dublin

1949 – Completes medicine and surgery internship at Joyce Green Hospital, London

1950 – Completes medicine internship at West Middlesex Hospital, London

1952 – Completes chest diseases residency at Clare Hall Hospital, London

1954 – Becomes registrar at Middlesex Chest Diseases Clinic, London

1955 – Completes medicine residency at Royal Free Hospital, London

1956 – Becomes registrar at Rheumatic Diseases Unit, Royal Free Hospital and Medical School

1960 – Becomes instructor, department of internal medicine, University of Texas Southwestern Medical School

1961 – Becomes assistant professor at the University of Texas Southwestern

1964 – Becomes associate professor, department of medicine, University of Cincinnati

1964 – Becomes director, division of immunology, rheumatology, and allergy, University of Cincinnati

1969 – Named McDonald Professor of Medicine, University of Cincinnati

1977 – Becomes professor of medicine, University of Cincinnati

Gretchen Henkel is writing the “Metrics in Rheumatology” series.

References

  1. Hess EV, Ashworth CT, Ziff M. Transfer of an autoimmune nephrosis in the rat by means of lymph node cells. J Exp Med. 1962;115:421-438.
  2. Hess EV, Ashworth CT, Ziff M. Nephrosis in the rat induced by rat extracts. Ann NY Academy of Science. 1965;124: 323-328.
  3. Hess EV, Fink CW, Taranta A, Ziff M. Heart muscle antibodies in rheumatic fever and other diseases. J Clin Invest. 1964; 43:886-893.
  4. Hess EV. Are there environmental forms of systemic autoimmune disease? Env Health Perspect. 1999;107:709-711.
  5. Miller FW, Hess EV, Clauw DJ, et al. Approaches for identifying and defining environmentally associated rheumatic disorders. Arthritis Rheum. 2000;43:243-249.

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