so much so that at a time when the surgical world was embarking on heart transplants in the 1970s, diagnostic criteria for PsA was just beginning to be identified, with few studies in adults or juveniles before the 1980s.15,16 Those early diagnostic criteria included dermatologic signs and joint pain but excluded more complicated, internal factors, such as bowel inflammation.17
Expert rheumatologists develop a sensitivity to subtle signs so they can typically identify conditions as being within the family of rheumatic autoimmune disease quickly, but even then, complex cases like Kerby’s are more challenging to diagnose.
Considering that many patients only see a rheumatologist after months, or even years, of seeking medical care for their strange array of complaints, it makes sense that diagnostic delay remains the norm for most people eventually diagnosed with PsA.18 For those whose symptoms have been laughed at or dismissed as psychosomatic, a diagnosis validates suffering. A diagnosis, for patients like Kerby, makes them tentatively willing to crack open the door to medicine again, hoping that this time medicine and its providers won’t let them down.
Unfortunately, treating rheumatic disease can be frustrating for both providers and patients. Rheumatologists may work 80–100 hours a week, opening their laptops after dinner and working until late into the night, only to get up again by 4 or 5 a.m.
Many rheumatologists juggle multiple research projects and collaborate across time zones and continents to conduct clinical trials with large enough sample sizes to find patterns and develop better treatments for their patients. Such research is more often characterized by years of careful work to gain an inch of insight than by major breakthroughs. Even so, the cultural myth of medical miracles dominates everyday expectations of medicine.19 These cultural myths are perhaps a particularly sharp, double-edged sword for rheumatologists.
Rheumatologists have preexisting social capital from the glow of normative cultural admiration for physicians. But given that rheumatic diseases are so complex and dynamic, that research is underfunded and that pharmaceuticals are difficult to develop, the cultural expectation for treatments that can always keep pain at bay and maintain daily functioning is frustratingly unrealistic.
Pharmaceutical companies and the rheumatologists that partner with them continue to strive for silver bullets; they want them so badly that unexpected adverse events might not at first be recognized.
Kerby had gone through a long list of medications for his PsA, and none of them worked any longer. Looking for a new medication, he enrolled in a drug trial for a medication that other patients with refractory disease had responded very positively. Indeed, the findings were so positive in others that when Kerby asked whether the drug could be linked to new tingling sensations in his knees, the providers in the room laughed.
That laughter, which Kerby had heard so many times since childhood, communicated that Kerby’s report of his own sensations was preposterous. It was laughable. His reality had been dismissed, and Kerby felt himself flush, absolutely embarrassed.
A few weeks later, after a stronger adverse event, no one laughed. The impossible had become possible, a unique allergic response to what had been thought of as a miracle drug.
Laughing at the Unexpected
Laughter bursts forth sometimes not because something is funny, but because something is so unexpected, so embarrassingly overwhelming, that laughter becomes a defense against a reality that doesn’t make sense. But for people living that nonsensical reality, laughter may
