It's Monday morning and my first patient is a newly diagnosed rheumatoid. This is his first visit back after starting methotrexate 6 weeks ago.
Despite doing great and in remission with only one active joint, he asks, “Are sure this is RA? Or could this be Still’s disease?”
Admittedly, this is a weird second-visit question, but I was impressed. It seems the patient must’ve googled me, read my online bio or seen that I am the self-declared, world-expert on this very rare condition, Still’s disease (a title and claim that garners no competition).
Much to my deflation, he informs me “Still’s” was the illness featured the movie he saw last weekend. A popular romantic-comedy entitled “The Big Sick”. The movie yet is another one of those Pakistani comic falls in love with a waspy psychology grad student, with happy, sad romance gone bad by illness.
It seems she twisted her ankle, developed a lung infection that requires intubation and a medically-induced coma and undergoes numerous antibiotics and diagnostic delays without a diagnosis, until the big reveal. Yes, 30 minutes of movie lament and hospital drama was all due to Still’s disease. While you were at the popcorn stand, she was quickly cured by mere anti-inflammatories!
Oh my, a movie about rheumatology and Still’s disease! I could hardly contain myself till the weekend, when I could take it all in and see why this is a 4-star movie has a Rotten Tomatoes 98% rating. The Big Sick is a big summer blockbuster, sleeper-surprise rom-com, and could be the first and only rheumatology Golden Globe award winner. Oh the anticipation!
I saw it and yes, everyone I’ve spoken to loved the movie, except for me.
No I’m not a persnickety highbrow academic or movie historian. I love movies, drama, comedies, documentaries and even chick-flicks! Yet, this one rubbed me wrong.
I found the movie to be a quirky, modestly humorous, very well-acted and predictably crafted emotional roller coaster, chick flick. Not really a problem so far, but clearly this is not nearly on my top shelf with The Dirty Dozen, Caddyshack or Forest Gump. It was sort of a cross between Coming to America and Guess Who’s Coming to Dinner (editor’s note: I’m dating myself with the last reference). Holly Hunter (the mom) and Ray Romano (the dad) were superb and worth seeing. And the young stars (heretofore unknowns) were believable, likeable and funny.
My problem is that The Big Sick unfortunately vexed me in 3 big ways.
- Where’s the Heroic Rheumatologist? If the emotional pivot of the movie hinges on the diagnosis of Still’s disease, where’s the heroic rheumatologist? My guess is that a) she/he ended up on the cutting room floor like our next round of Medicare reimbursement cuts, or b) the heroic rheumatologist wannabe took too long to explain Still’s, or c) the diagnosis was made by IBM’s Watson program. Why is the ACR spending all their time and resources on Capitol Hill lobbying when they should either be investing in cinematic features with heroic rheumatologists or finding famous people with arthritis who we (not pharma) can parade in front of the public? (I do hope a task force on this is forth-coming.)
- Where’s the Still's disease? Sorry to flex my expertise here, but nothing about the on-screen illness resembles Still's disease. The patient never had the triad of spiking fever, evanescent rashes and polyarthritis. Instead, they declare, “all her vital signs are elevated” (while she looks make-up sick with a RR of 14 and heart monitor reading of 61). Her arthritis is one swollen ankle that never resolves (yet synovitis in Still's disease is symmetric polyarticular and never a monarthritis). No rash, no spleen, no sore throat? The rest of the movie focuses on a lung infection (empyema?) that spreads to her heart and kidneys (sorry these would all be rare in Still's disease or systemic juvenile idiopathic arthritis). I do consultations on a lot of patients with presumed or diagnosed Still’s disease and unfortunately, the vast of the majority do not meet Yamaguchi or Cush Criteria for the diagnosis. Most these patients started out with a fever and because of fever or an elevated ferritin (sorry folks, it’s just another acute phase reactant) they are given a stump-the-chump default diagnosis of “Still's disease”. My advice for those considering this diagnosis is to read the two original papers by Sir Eric Bywaters (http://buff.ly/2uXSlJD) and Joseph Bujak (http://buff.ly/2tAXqUQ) from the NIH. These papers reveal the symptom sequence, scope of involvement and severity of disease required to make this diagnosis.
- Don’t go to Medical Movies with a Doctor! The real sick here is what happens when a doctor goes to see a movie that involves a sick patient, medical illness, or medical intervention. Whether you’re the doctor or one who has to put up with a doctor, you know the scenario. In the movie middle, during nothing particularly important, you (the doctor) become incensed, throw your hands in the air, roll your eyes and blurt “oh my gosh”. What follows is uncomfortable movie under-talking to detail the implausibility, impossibility and contradictions to standard medical care being espoused on screen. This happens in the movies, on TV, and heck, even in hospitals (and that’s when risk management gets called). We doctors are all a bunch of know-it-alls looking for an audience. Movies are probably not our best choice, since those other audience people are there for the entertainment or a few tears. Not for your powerpoint analysis of why the PCP shouldn’t be in the operating room, etc. Likewise, cinematic miracle cures from vitamins make for gripping drama and tearful endings. But not for the doctor, who ranks such as irresponsible malpractice being committed by starlets and key grips. The only solution is to have special screening times and locations for doctors who wish to see movies with medical content or scientific subtitles. Afterwards, they can convene, debate and write letters to the editor that will never be seen.
Epilogue: Despite my rants, I’ve been told this is a true story and that the lead actor’s girlfriend actually has this illness and is receiving treatment for it.