These two reports of associating selective perturbations of the immune system with specific clinical syndromes should not be surprising to rheumatologists. These observations are simply elegant and a contemporary extension of principles familiar to us. They remind us of the intricacy and complexity of immune homeostasis and that there are doubtless many more such examples to be identified. Indeed, a very nice paper appeared in the Journal of Immunology (2010;184:4605-4609) showing that IL-23R–deficient lpr/lpr lupus-prone mice were protected from lupus nephritis. IL-23 is important for proinflammatory Th17 cells implicated in the pathogenesis of lupus.
Nature here is trying to teach us something. These examples should suggest both clinical and therapeutic insights. What gene mutations will be associated with what symptoms? To what might heterozygotes be predisposed? Can we develop therapeutic interventions affecting IL-17 and IL-22 without attenuating host defenses? We should look for such contributions in future literature.
ON PROFESSIONALISM
“In a place where there is no man (of integrity), strive to be one” is a loose translation of Talmud Avot 2:6. I always interpreted this as an exhortation to character, decency, morality, high ethical standards, and menschlichkeit— “professionalism” in medical terms. After problems with money and regulatory requirements, issues of physician behavior are probably most challenging to those of us in leadership positions in medicine. This article reminds us that physicians suffer the same foibles as mere mortals. Some behave poorly and others cross the pale into criminality.
I’m now in my 35th year as a division chief or department chair. I see much to savor, appreciate, and celebrate every day and every year—spectacular individual and collective professional accomplishments at the bench and the bedside. They can be extraordinary, particularly when viewed through the perspective of four decades. But I also see things that profoundly disappoint, indeed disturb, me. One of these is the sometimes disheartening lack of professionalism in our profession. I’m anguished in my roles as mentor, supervisor, teacher, professor, program director, and institutional and organizational leader when I witness how badly we sometimes do this. I’ve editorialized about my profound concerns with our failures of ethics in relationships with industry and, yes, even in our ACR.
This selection highlights another concern about which I’ve privately worried greatly: how badly we sometimes behave toward one another and toward subordinates. There is a depressingly robust literature about professional misbehavior by colleagues, residents, students, and others; it is pernicious and pervasive. We have documented this at our institution and it troubles me profoundly. We have had shouting, yelling, accusations, harassment, probably destruction of data, and real threats of and acts of violence. During my many years of active participation in the ACR, we had some similar experiences. The daunting question is what to do to remedy this. I believe that, just as we must accept responsibility for the dilemma, we must develop a solution. I can no longer tolerate colleagues acting disrespectfully to one another, regardless of the times, circumstances, or provocations. We must do better, and I sincerely believe that we can.
