Dr. Weishali Joshi

Saint Francis Hospital and Medical Center rheumatologist Dr. Weishali Joshi always wanted to be a doctor. She excelled in her studies and started medical school at Grant Medical College in Mumbai when she was just 16 years old.

Little did she know at the time that her medical career would take her halfway around the world.

While completing her medical school and residency training in internal medicine in western India, she imagined she would eventually practice in her home country. But when her soon-to-be husband, also a physician, decided to pursue a career in endocrinology – and set his sights on training and research opportunities at the University of Connecticut – that expectation changed.

“We were married, he came to Connecticut for his residency, and I followed,” says Dr. Joshi.

RHEUMATOLOGY: “A CALLING FROM ABOVE”

Arriving in the U.S. when she was 25 years old, she took her licensing exams and did a second internal medicine residency, this time at UConn’s School of Medicine. She joined the staff at Saint Francis in 1999 as an attending in the hospital’s ambulatory care center, where she worked for 11 years.

“I never thought I would do a fellowship,” says Dr. Joshi. In fact, she recalls that when the residents working in the clinic would ask her for career advice, she would counsel them to do a fellowship immediately after residency, “or the opportunity to do a fellowship significantly decreases.”

But one day, while chatting with her clinical director, she mentioned in passing that if she could do any fellowship, she would choose rheumatology.

“That same day, we found out in a meeting that Saint Francis would be sponsoring a rheumatology fellow, and my boss said, ‘This is a calling from above; you should pursue this.’ ”

Despite some reservations – she was already 41 years old and a mother of two young children at the time – Dr. Joshi applied for and was awarded the fellowship position at UConn.

Upon completing her rheumatology training, she took another position at Saint Francis as a rheumatologist.

“It was literally a no-brainer. I didn’t look anywhere else,” says Dr. Joshi. “Saint Francis is home.”

What drew Dr. Joshi to rheumatology was the complexity of the specialty and its multidisciplinary nature – rheumatologic conditions can involve all the different systems in the body.

“We used to see a lot of rheumatologic problems in the clinic, like joint pain and musculoskeletal issues,” Dr. Joshi recalls. “We would diagnose them and send them to rheumatology and patients would be put on all these cool medicines and then feel better. So I was very intrigued.”

In fact, these “cool medicines” – the so-called “biologics” – were increasingly used in the years leading up to Dr. Joshi’s certification in rheumatology and have revolutionized the treatment of rheumatologic conditions such as lupus and rheumatoid arthritis (RA). Unlike chemical-based drugs, biologics are cell-based, produced through biotechnology methods and other cutting-edge technologies.

“We do not want to see anybody with RA disabled or with deformities that impact their ability to function day to day,” says Dr. Joshi. “With the biologic therapies, people with rheumatologic conditions are now expected to have a normal quality of life, free from pain.”

DIAGNOSING: MEDICAL DETECTIVE WORK

Rheumatologists treat illnesses involving the joints, muscles and soft tissues, including many autoimmune diseases – conditions in which the immune system goes awry and starts attacking healthy tissue, mistaking the body’s own cells for foreign invaders like bacteria or viruses. There are more than 100 different autoimmune diseases, but the most common ones that Dr. Joshi treats are lupus, RA, ankylosing spondylitis (AS), scleroderma, polymyositis (PM), and Sjögren’s syndrome.

“Usually, patients are referred to me because of joint pain, or because they have tested positive on certain diagnostic tests,” says Dr. Joshi. These might include the ANA (antinuclear antibodies) test, which indicates that there are antibodies in the blood, or others that detect the presence of inflammation in the body – like the CRP (C-reactive protein) or sed rate (erythrocyte sedimentation rate) tests.

“I take the patient’s history, assess the pattern of their symptoms, and in some cases can make a bedside diagnosis,” she says. “What is their age? Is their pain associated with activities, or does it wake them from sleep at night?”

RA and osteoarthritis are more common later in life, she says, while lupus is more likely to strike women in their childbearing years. If a young patient comes in with back pain, Dr. Joshi says she is more likely to consider AS.

“Medicine is detective work,” she says, “You take the patient history and you go by experience as well. No two patients are alike. You need to use clinical judgment.”

The American College of Rheumatology also offers guidelines and specific diagnostic criteria that aid doctors in teasing out the cause of a patient’s symptoms. There are many different types of arthritis, for example. Someone with RA, Dr. Joshi says, typically has morning stiffness, and the small joints in the hands are likely to be affected. In osteoarthritis, there is less morning stiffness and more pain after they’ve used their hands a lot. In psoriatic arthritis, patients tend to have something called “sausage digits” due to inflammation in their fingers; and patients with arthritic pain who have a history of bug bites might have Lyme-induced arthritis.

Part of her job, says Dr. Joshi, is allaying her patients’ anxiety and reassuring them that whatever they’ve diagnosed themselves with after researching their symptoms on the Internet doesn’t necessarily apply.

“That’s half the battle right now,” says Dr. Joshi. “There’s such an overload of information out there, and so many myths.”

THE EVOLUTION OF THE BIOLOGICS

Dr. Joshi remembers the first biologic – infliximab – appearing on the market around the time she finished her residency.

“At the time, there was a lot concern about the drug causing infection, reactivation of tuberculosis, and malignancies. There were many side effects,” she says. “I thought, ‘Who in their right mind would give these medicines to anyone?’ ”

Today, she says, the biologics, also known as monoclonal antibodies, have fewer side effects and have had a huge impact on the treatment of rheumatologic conditions.

Monoclonal antibodies are basically clones of antibody molecules that enlist the body’s immune system to help fight disease. In the case of the autoimmune disorders, these “fake” antibodies bind to the cells that cause inflammation, thus inhibiting their action.

“These drugs block the processes that cause tissue damage,” explains Dr. Joshi.

As the biologics have evolved, they have become more targeted. More and more research is going on to figure out what specific cells to target, she says. Cytokines are cell-signaling molecules that call other immune cells to the site of inflammation.

“Scientists are learning which particular cytokines cause the most pathogenesis [origin and development] of a disease, and targeting the drugs to those cytokines,” says Dr. Joshi.

Disease modifying agents like methotrexate and biologics like etanercept (Enbrel) and adalimumab (Humira) are so successful at controlling patients’ symptoms, she says, that rheumatologists are now faced with the dilemma of whether, and when, to taper or discontinue them.

“These are all chronic diseases; they are not going away. These drugs keep these diseases under control, but don’t cure them. And they do still have some side effects. So you have a patient with RA who is stable. Now do you take the plunge and taper or discontinue therapy? Or is that going to cause worse damage? That is one of the questions I ask myself every day.”

Though the biologics are very expensive, the recent emergence of “biosimilar” drugs, which are basically the generic versions of biologics, should help alleviate the financial burden of treating these disorders, she says. Dr. Joshi supports patients trying complementary therapies like acupuncture, meditation, or turmeric, a natural anti-inflammatory that has been used as a medicinal in India for centuries.

TEACHING AND TREATING: A REWARDING COMBINATION

Part of Dr. Joshi’s job is teaching UConn residents and Saint Francis fellows.

“I love teaching,” she says. “The focus on teaching and education at Saint Francis was a big part of me coming back to the institution after the fellowship.”

But her greatest satisfaction has been witnessing the huge difference that medicine can make in her patients’ lives.

“We see patients who cannot do anything – they’ve been out of work for two months, their hands are hurting, their bodies are hurting,” she says. “Just seeing them get back to work and their normal lives, seeing how stable they are and how well they can do on these medications, that has been the most rewarding thing for me.”

Dr. Joshi lives in West Hartford with her husband. They have two daughters – one is a second-year medical student and the other is a college sophomore, pursuing a science, technology and international affairs major. When she is not working, Dr. Joshi enjoys playing tennis and practicing a classical form of Indian dance called Kathak. 

Lori Miller Kase is a freelance writer living in Simsbury.

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