How I Got a Date with Jeremy Irons in a Castle in Spain and How a Size Two Diva Went Shopping at Lord and Taylor for a Size Fourteen Suit

I was giving a lecture in London, in the Victoria Auditorium of St. Martin's Academy of Science. Sunlight streamed through slits in the black velvet curtains, but overhead the massive chandeliers were dimmed to almost nothing. A polite crowd of dark suited Europeans sat quietly in elegant, carved chairs under a long line of portraits of eagle-eyed 19th Century Professors with substantial facial hair, who seemed to join my living audience in rapt attention to what I had to say, as I clicked through my power point slides.

What I had to say was that there was a fatal flaw in the way we had been designing clinical trials for lupus over the past twenty years.

"WE WERE TOO LIBERAL WITH THE BACKGROUND TREATMENTS!" I yelled, pounding the massive podium.

Lupus is a complicated disorder of the immune system with frightening symptoms that come and go with no warning. Although there are overlapping clinical features from patient to patient, it is almost impossible to find any two people whose immune systems are imbalanced in exactly the same way.

Imagine how unpredictable this teeter-totter would become if you took 250 of these patients and they were on six or seven different combinations of background treatments, each one of which might tip the immune system in a different direction. But that is exactly the “background” against which we have been testing new treatments for lupus over the past twenty years. While failing miserably.

When patients enter a clinical trial for lupus they are usually maintained on their “stable background treatment” and then a new investigational drug (or an invactive placebo agent) is added on to that. Imagine if background treatment number one was so effective that the patients who entered the study on it and then got placebo kept getting better and better during the year until they improved so much that even an effective test drug could not look any better than that.

What if Background treatment number two had the same effects on the immune system as the treatment being studied? It would seem likely that for the patients on this background treatment, the test drug and placebo would also do about the same.

Now what if Background treatment number three had effects which clashed with the investigational treatment? When you got them both together they cancelled each other out. Then the group on that Background treatment who got the test drug might even do worse that those who were on placebo, who could at least get some benefit from that background treatment with nothing clashing against it.

No wonder it has been so difficult to interpret the outcomes in lupus clinical trials.

Not only did I discuss theoretical reasons why this might be the case, but I showed specific data from two of the recently unsuccessful trials. If you looked at the outcomes of the subset of patients on one particular background treatment, there was no difference between treatment and placebo, but if you looked at those who participated in the same study on a different background treatment, there was a clear difference.

But after spending gazillions of dollars on that clinical trial, where overall you could not see any benefit to their drug, the company stopped developing it for lupus.

I then proposed a clinical trial design that could begin to solve this problem and got a roaring standing ovation.

I was wearing my practical black travel clothes, but I had on a bright red silk jacket from Shanghai over them, and I thought I looked fantastic, despite a few extra wrinkles on my neck from sleeping on an airplane.

Later I rode the Underground to Leicester Square, bought a theatre ticket for later that night, and walked to Hyde Park corner. Once, many years ago, I did that same identical walk carrying a copy of Boswell’s “Life of Johnson

If you want a great vacation I recommend you take one of Boswell's books to London some summer. Sit in Kensington Gardens or take a boat ride down the Thames and keep reading that book, it is like a guidebook to the past, but in modern London a lot of what Boswell describes is still there. Meanwhile, do you think this blog is funny? Read that one!

And it is full of important romantic advice.

As I walked my own favorite mile of Boswell’s London, where major landmarks have barely changed since the 18th Century (knowing that I was being recorded by the secret cameras they have peeking out to spy on you in London now from behind every scultpted cornice), I experienced the letdown you always get when a great performance ends and the show closes.

Applause is a supreme high, but for me it is always followed closely by a letdown when I walk out on the street and realize that nobody there cares whether I live or die.

Why do you think I like to play the BIG MOUNTAIN SNOWBOARDING iPhone app so much on my iTouch? That game is a lot like my life. So far I have reached the bronze level on it. I have learned that when you go up a slope you should quickly lift your gizmo up and then start angling it. Your little snowboarding mannekin will lift into the air and start flying and spinning.

The more tricks you can do in mid-air the more points you get and the points float up the screen like applause. But if you do not stay on task during the landing he will end up pointing sideways and he will bump into a tree or start meandering up against a cliff or....he slows down to a stop.

Then you have to give the gizmo a little shake to make him start moving again. Much like my life.

You may be better off obscure and happy with a man who really loves you. But then again, how would I know? I recommend that you play BIG MOUNTAIN SNOWBOARDING a few times and ask yourself if you can handle this sort of life. You can get this at:

www.gamespot.com/iphone/action/bigmountainsnowboarding/index.html

A few months after my existential moment in London I was traveling again when I received two emails from the American College of Rheumatology inviting me to present the data from two failed multicenter clinical trials in a huge auditorium at the National Meeting in Boston. I immediately broke into a sweat and phoned Diva.

“What am I going to do?” I screamed. I have two big important talks and they are both about failed clinical trials.

“So what? You will turn it into a great platform for yourself. I am so jealous,” Diva complimented me.

“The companies won’t let me turn it into a platform,” I sobbed. “The FDA won’t let them!”

If it were up to me to explain what was going on in these trials, I might start by showing something fascinating about how the drugs work and then report that the trials didn’t work out so far and suggest some reasons why. Ooops. That’s backwards. What I should do is start by saying the trials didn’t work and then dissect all the trouble with clinical study designs in lupus and end with my proposal for a new study design suggested by the failed data.

As I have discussed in a previous blog, the order in which you reveal important information is critical both in business and in romance! (See “Sealing the Deal”, posted several days ago).

“I am so upset,” I wailed to Diva. “You know the kind of talk I could give and I won’t be allowed to! Remember how well that paid gig went in London in June!”

“Of course, I was so jealous I was planning to have you assasinated, and they paid for Business Class, too.”

“Well it won’t be like that this time. Not with ACR abstracts. I will have to stand by for an upgrade, and they will make me show fifteen redundant data slides where there is no difference between treatment and placebo and then ten more slides of boring safety tables. There won’t be any time at all to say anything interesting. Everyone will be snoring by the time I get through that.

“Stop worrying, you will think of something to make it memorable.” my loyal best friend assured me.

“Your total confidence in me is amazing,” I told her.

“Well I don’t know about that,” admitted Diva. “What are you going to wear?”

Diva considers my practical, versatile travel wardrobe (which allows me to fly around the world for a week with only two carry-on bags including my laptop case) to be ‘old lady knits.’ Whenever I get an important talk at the ACR or EULAR, Diva always puts her foot down and forces me to buy a new designer suit.

In whatever size I am at the time.

Fortunately, I was in Dallas when we had this conversation, and there was an upscale mall right across the street from my hotel. Diva was in San Francisco, about to go home to New York.

“How was your Ad Board meeting?” she asked me.

“I was the smartest person,” I assured her. “How was yours?”

“I was the smartest person,” she said. “Well good luck, buy a suit today, you only have two weeks before you come to New York, and I have to see you in it before we decide how to have it altered.”

I could tell Diva was antsy to hang up on me, and I figured it was because she wanted to catch an early flight home. She hates airplanes.

Ad Boards, (or Advisory Boards) can be one of two things.

1. Vanity consultations where lower level functionaries from a pharmaceutical company pays local doctors a generous honorarium to sit in a room while they show slides to push their products. Then the doctors fill out a form in the end to give advice about marketing the product that nobody pays attention to.

or….

2. Critical meetings of the coolest people in the industry, where they pay experts in the field a generous honorarium to help them figure out why most of the clinical trials for lupus have failed in the past twenty years and what kind of trial design to try next.

And how to talk their top management into paying for another clinical trial for our godforsaken disease.

Diva and I used to do both kinds of Ad Boards, but now we only do the second kind. One of the reasons for this is that our NIH-funded institutions do not like us to participate in anything that might be construed as commercial frippery. The other reason is that we have now climbed a little higher in the academic-industrial world and we are too busy going to type 2 meetings to have any time for those easy money type 1 meetings.

You may be wondering what this has to do with romantic advice.

Everything.

I have already described to you some of the worst dates I have had, mostly with random men from the Internet.

The best dates I have ever had have been with men I have met in the wide world of my career. And these meetings have invariably taken place in the context of some Type 2 Ad Board where I was the smartest person in the room, or after a great talk that I gave in a large auditorium to loud applause.

No kidding, independence, self-sufficiency and fame can get you dates.

No wonder I am confused by a woman who takes over a man's kitchen and makes him drive her to the airport.

You don’t believe that I can get great dates after behaving like a person who needs noone? Ha. I once had a date with Jeremy Irons in a castle in Spain.

Not Jeremy Irons the movie star, Jeremy Irons the rheumatologist. Still, if anything, this guy is even more handsome and drop dead classy than the actor. Or at least middle classy, but if you sat all the way through Brideshead Revisited, you know that was exactly the character that Jeremby Irons (the actor) was supposed to be playing.



My date with Jeremy in the castle occurred at the International Lupus Meeting which was in Barcelona a number of years ago. About three weeks before that, Diva and I had been doing a type 2 Ad Board with Jeremy in San Diego and he and I had gotten into one of those lethal arguments that should be avoided at all costs in a collegial setting.

Jeremy had an idea that at the beginning of each clinical trial the investigator should just say “what is the main symptom being treated” and let the outcome be “whether that thing got better.” He thought this was the best way to avoid the confusion of symptoms that make outcomes of lupus trials so impossible to interpret.

He thought that if a person comes to the clinic with a little rash on their cheeks that they don’t care about and a little sore in their mouth that they know will get better on its own in a few days, and they also have severe arthritis that is making them miserable, it should not matter, in a clinical trial if there is still a little rash and a minor mouth sore left after you test a new treatment, as long as the arthritis gets better.

He was absolutely right about that, and his idea has become an underpinning for the clinical trials solutions that I think may turn our entire industry around.

But when Diva and I first heard him suggest this idea at the Ad Board in San Diego, we were at least three failed clinical trials away from recognizing how prescient he was. We also knew that at that time the FDA would never go for a trial design that was based on something a clinician just thinks up in clinic, they like outcomes to be measured with “validated indices.”

Diva and I didn’t’ know Jeremy very well back then, except from a distance. Once, a few months before we met up with him at that Ad Board, he had been going up an escalator at the EULAR meeting when we were going down, and Diva had pointed him out to me as an example of the perfect man.

We both knew his reputation, of course. We knew that he had cured the NZB NZW mouse model of lupus with a combination of chemo and a targeted biologic treatment when neither one of them worked alone. He had given a big talk at the EULAR meeting and Diva had been sitting next to me in the audience practically drooling over him.

“I am so in love with him, he is the most romantic guy in rheumatology,” Diva had said. “His beautiful wife died and he is heartbroken over her and he is so brilliant and handsome....”

"Shhhh," said an annoyed scientific delegate behind us who was trying to hear the talk.

“He seems nice and he is gorgeous, but he has a whiny voice,” I pointed out.

“What are you talking about? He has a mellifluous voice like a radio announcer. It sends shivers down my spine!” Diva raved

The guy behind us gave an exasperated sigh, got up and moved to another part of the auditorium.

Now we were sitting in a small room with him and five high powered Japanese Pharmaceutical VPs. However, now he was sending a different kind of shivers down our spines. Scary shivers. He was using tricks to make us look bad and make himself look good.

Whenever the company guys asked a question, he would demur that he needed to reflect on his answer, and request that Diva and I each say what we thought first. While he acted like he was meditating. Then, when we were done he would lift his head and render his opinion, and try to make us look bad.

His way of talking was slow, contemplative, full of long, thoughtful, portentious pauses that made the drug company people lean forward expectantly, and he frequently got his facts wrong.

He would also pepper his remarks with humble disclaimers and complimentary remarks aimed at us to make himself look like a nice guy, before softly, sweetly and regretfully over-ruling each thing we said.

At first we let him get away with it, hoping this would turn out to be an anomaly, but to our mounting horror he kept doing it, again and again.

It is not that Diva and I have trouble entertaining an opposing point of view, it is just that we have both become used to the extra income we get, doing one or more Ad Boards each month, and his manner of rendering a consistently negative verdict on us felt like he was jeopardizing our creds!

We met up in the ladies room after the second break and I told Diva to stop staring at him like a swooning schoolgirl and she told me to stop worrying about offending her, just let him have it.

We went back in the room and started haranguing him like fishwives every time he opened his mouth, blocking him at every turn with our superior knowledge of the facts.

Despite our inferior vocabularies, and our more shrill tonal nuances.

It was obvious to Diva and I that we knew more stuff than he did. And it was gradually becoming evident to him to, each time we countered his frail assumptions with the data. As the morning wore on he was getting really mad at both of us.

Especially me.

He kept saying “Don’t interrupt me, Della,” in a really angry and offended voice.

If you have been reading this blog for a while, you will know that quite a few men seem to say this to me. But this time I was in a professional situation. With Japanese people. I was on my best behavior there. And I was innocent.

Here is an example:

“I may be wrong," he began at one point. “In fact it must be obvious to everybody that I have been wrong from time to time...” looks down at his hands modestly as if he is waiting for someone to contradict him. “….but what I would like to suggest….that is, if this opinion could be considered a suggestion only, since I certainly would not want to assume that everyone would agree with it....” he smiles at me. “...so what I am only SUGGESTING….” he continues sweetly, “is that the BILAG is far too complicated an outcome measure and you are unlikely to acquire interpretable data from it.”

I wait politely. There is a six second silence.

“That’s not true!” I yell.

“Do not interrupt me, Della,” he says angrily. “I have the courtesy not to interrupt you, and all I ask is that the same courtesy be extended to me.”

A very difficult man. Not to mention how off base he was with the facts.

The BILAG is the British Isles Lupus Activity Group Index, and it is the only validated measure for lupus that actually works. Some of the time.

It has been widely used in clinical trials for lupus, all of which failed. No wonder people who don't know what they are talking about are beginning to suspect that there is something wrong with the BILAG.

But these trials have failed primarily because of the choice of what to measure, not because the BILAG measuring tool is no good. In other words, if you are looking for a change in millimeters that you should have been measuring in centimeters, and the outcome doesn't make any sense, it is because of an error in your choice of increment, not because the ruler is broken.

All of which I said, while he got madder and madder at me, because in his mind I had interrupted him in the middle of one of his interminable pauses.

In my mind the matter was simpler and less personal. I knew a whole lot more about the BILAG than he did. And I knew a whole lot more about patients, too. This guy was a mouse doctor. What did he know about human patients in clinic?

There is a beautiful piece of work by a guy in Texas who took a lupus mouse and bred it to a healthy mouse. All of the offspring had some laboratory features of lupus, but none of them got sick. He identified three different regions in the genes that could be identified in three different types of the offspring mice. Then he started mating these baby mice together. If you combined baby mouse one and baby mouse two, very few of them got sick. If you combined baby mouse one and three about half of them got sick. So does that mean that regions one and three are important and region two is not?

Here is the interesting part. If you did some complicated breeding experiments, and ended up putting together baby mice one, two and three so that you got all their genetic elements put back into one mouse, guess how many of those offspring got sick? More than 90%. This suggests that whatever number 2 had was important after all, but only when it has a full set of the other lupus puzzle pieces on board. This was a plenary piece of work that explains some profound issues about how genes interact with each other.

But if you are a human and everybody else in your population is not inbred by scientists to resemble each other, you can inherit a whole lot of different genes. Some genes work with other genes to increase their impact and some genes work against the effects of other genes. We already know there are hundreds of genes that can increase the risk to get human lupus, not three. It is possible that it could be thousands of genes in fact.

And every human lupus patient can have a different subset of these genes working together (or working against each other) than every other lupus patient. This is just to say that human lupus is a lot more complicated than mouse lupus. There is a lot more to measure there. And yes, Jeremy Irons, we do need the BILAG.

But it was very hard to get this message across to the people of Takada Horita Pharmaceutical Company, when every time I spoke I was accused of interrupting and every time Jeremy Irons said anything he first looked humbly down at his hands and made some likeable, self-disparaging remark in his mellifluous radio announcer voice. He had the Japanese culture down pat and what were we supposed to do? Turn into Geishas?

And then with an inexplicable assumption of finality, he rendered the final verdict on every topic, simply over-ruling the girls with a dulcet finality that brokered no response. And the Japanese guys were eating out of his hand.

Diva and I had never dealt with anybody like him before.

At the end of the meeting, he had done us some damage and we had done him some damage and I guess it was a tie.

He shook hands and bowed with all the drug company people, gave a curt nod to Diva and gave me a long, scary stare. Then he quickly left for the airport.

Diva and I were booked on the same initial flight to Chicago where we would be separating for connections to our home cities. I figured we could discuss what a jerk Jeremy was on the airplane, and I was looking forward to that because I was still riled up.

“Was he an ignorant jerk or what?” I sniffed as the plane started lumbering down the runway.

Diva was gripping her armrests with white knuckles. “Wait, “ she hissed. “Wait until we make it up......ahhhh....ahhhh...Oh,no! Oh no! What was that?”

The plane had shuddered a little. “Just a normal vibration.” I said. “They call it the vibration of acceleration.”

The plane was lifting. Diva shank in her seat. “Is that normal?”

“Is what normal?”

“The vibration thing. The acceleration thing.”

“I don’t know," I giggled. “I made it up.”

“I never felt anything like that before." she said sternly.

"Happens all the time and you know it," I soothed her.

Suddenly she stiffened in her seat. "I think our angle is wrong. this isn’t normal, we aren’t getting enough altitude!”

“No, no, no, perfectly normal. They take off in different ways sometimes.”

“Why? Why would they do it any different way? Why can’t they just do it normally?”

“You know, wind, air traffic, birds….”

“BIRDS? BIRDS? BITE YOUR TONGUE!”

The plane angled up a little more, and we were climbing steadily now. She started to relax a little.

“Let’s get a drink, “ I said. “As soon as the flight attendant gets up.”

I love flight attendants. They take care of us frequent fliers when we are nervous and tired and cranky. Especially the First Class flight attendants, when we get upgraded.

I peeked down the aisle and saw ours unstrapping herself and getting up. She had aleady seen me and nodded at me.

“Was that really a normal takeoff?” Diva asked me.

“Diva,” I said. “How many airplanes have you been on....just in the last year?”

“I am a Platinum now,” she said with dignity. “Now I’m almost as good as you." I am an Executive Platinum, but I am more loyal to one airline than she is.

“Congratulations,” I said. "You will be getting more upgrades now."

"Say," she mused, "I wonder if we get to exit first in a plane crash?”

“Let’s talk about Jeremy Irons." I said Isn’t he a jerk?”

“He was discusting,” she said. “And stupid. And boring.”

The flight attendant had picked up on my “four finger” sign and was pouring us some Pinot Grigio, but not in the miniature wine glasses they usually use if you only hold up two fingers.

“Diva stared wonderingly at the large plastic soda cup full of wine she had just been handed. “What’s this?” she said. “How did this happen?”

“I gave her the secret sign,” I said smugly.

I had learned this trick from a worldly Italian businessman in an Armani suit I once sat next to in First Class. You know, the type of really cool character who is known by headwaiters around the world and who probably paid full price for his ticket.

“Wow,” said Diva. “That was really nice of her.”

The plane gave a lurch and she took a huge gulp from her cup.

“Bird strike?” she asked me.

“Hard to say,” I said, “but....it would have to be a little bird.”

“How do you know that?’ She asked suspiciously.

“Because we didn’t crash,” I grinned.

“Yet,” she pointed out and drained her glass.

Fortunately, wine works quickly on her. A few minutes later she was grinning and holding out her cup as the flight attendant came back up the aisle.

“You know, she is primarily here for your safety,” I reminded Diva.

“Are you enjoying your flight?” the lady asked Diva as she liberally poured the cup full again.

“Shurtainly,” said Diva smiling at her goofily.

“Back to Jeremy Irons, I am having trouble figuring him out,” I mused. “You are so right about his voice. He is so mellifluous and you think he is being nice, so why was he constantly dismissing everything we said, but of course failing to humiliate us because we are smarter than him."

Somehow, even then, I must have recognized that if I didn't have a little crush on him I would have been working on my laptop by then, instead of talking about him. Do guys talk about girls on airplanes? I never heard any of them doing it.

“Jeremy? What did I say about him before?” Diva

“Discusting, stupid and boring.” I reminded her.

“True. But he is so mellifuel, melliflu-lous.”

“And he obviously doesn’t know anything about the BILAG,” I reminded her.

“And handsome, too, don’t you love his chin?”

“But boring, “ I said. "No sense of humor. None at all."

“And brilliant. Some of what he said today was ash-cually brilliant.”

“Yes,” I admitted, “but most of it was wrong.”

“But he is brilliant. Just admit it, Della.”

“And neurotic.” I proclaimed. “I think he is extremely neurotic.”

“He’s hot,” she said. “Just admit it.”

“I don’t think so.” I lied.

“We never like the same type,” she sighed, adjusting a pillow under her head and pulling the airplane blanket up to her chin.

“I can’t stand him,” I said defensively.

But she was already falling asleep.

Then we were in Barcelona, at the International Lupus Meeting. It was a mediocre meeting and Diva had been in a crabby mood ever since we found out our full priced American Airlines tickets were on a co-share with an Iberian flight that would have cost half as much if we had purchased it online through them in the first place. And this was one of those situations where we had to use our credit cards and get reimbursed once we got to the meeting, something that makes us both crabby. Me because I like to pay off my credit cards in full each month. Diva because she likes to complete her minimum payment in full each month.

Also, Diva hates Iberian Airlines because she thinks that Spanish flight attendants are haughty.

On the plane, when the lady had passed us for the third time with her nose up, ignoring us loudly snapping our fingers at her, I had tried to explain to Diva that haughtiness is a sign of firey beauty in Spain, related to the Flamenco dance and the tango, but she was remembering the full cup of wine we got on the American flight from San Diego to Chicago, and the chintzy little wine glasses we got in tourist class on Iberian.

There had been no upgrades on that flight. They had been snapped up by those of our colleagues who bought their tickets more than a month in advance. Diva had to take it out on somebody. You do feel the turbulence more in the tourist section, even I think so.

Diva also hated the hotel in Barcelona which made us wait three hours for our room after a harrowing, turbulent red-eye flight across the Atlantic followed by circling around Barcelona for an hour in a thunderstorm.

I should say the flight was harrowing to Diva, and Diva cowering in her seat and wimpering for eight hours was harrowing to me.

She also did not like the food in Spain. Or the small room they had assigned in the convention center for her plenary talk on neonatal lupus. Or the level of the science that was being presented by our colleagues. Or the way our ex-boss, the Screwdriver, had insinuated that I stole some grant money from him when I left Columbia University. Or the way our friend Martha’s paper (preliminary to the one that revolutionized the care of lupus patients, which came a year or two later) was ignored by most of the attendees.

Or the cost of a taxi to get across town to where the good shopping was.

Diva lives in an East Side Manhattan apartment with a terrace and a view of the Chrysler building, wears only designer clothes and recently bought a house in Ocean Beach which she is totally gutting and renovating with every penny she earns at Ad Boards and consulting on her cell phone with pharmaceutical investors. While I am trolling the internet for cute men, she is trolling Ebay for antique chairs for her apartment, or shabby chic bedframes for her beach house. This does not leave her much ready cash for traveling.



People who do not know Diva very well are often astonished when they overhear this woman in an Ann Klein suit and Christian Louboutin heels screaming about cab fares or some hotel bill that some company or university lectureship administrator forgot to pay in advance for her. Whenever possible she refuses to put down a dime for lodging, food, or transporation when she is traveling, but there are two very good reasons. 1.) She usually doesn’t have to. 2.) She requires every penny she earns to pay off her credit card bills for clothes and furniture, and she can’t afford any extra expenses for necessities.



Although my general finances are simultaneously more modest and stable than hers, I agree with her about the traveling expenses. If you pay for something that someone promises to reimburse later you only have a 50:50 chance of ever seeing that money again. And then only after wasting hours of your time writing invoices and sending irate emails. Then try having 20 outstanding invoices to twenty meeting planners whose names do not match any event you went to, and figuring out which ones have already been direct deposited and which have not.

So on the night of the Gala dinner, we were both feeling very strung out because we had discovered that morning that the Congress had still not pre-paid our hotel bill. Very likely we would be stuck with it when we left. Now we were waiting wearily in 90 degree weather surrounded by 2,000 other scientific delegates, slowly inching along a line for the three or four busses that were driving back and forth ferrying everybody bit by bit to some fancy castle, five miles away, where the dinner was supposed to be.

“Let’s face it, the pre-planning is terrible at this meeting. Let’s leave,” I said to Diva. “Why are we standing here like this?”

“Pay for dinner? No way. Just wait a little longer,” she said.

“Yeah but once we get there we will be stuck. Trapped. If this is how long it takes to get there, imagine how long they will take to bring us back. We will have to stay for the whole boring thing with the stupid awards ceremony and the stupid jokes and that boring dermatologist from Boca Raton singing “Memories” and Rudy Costanza playing polkas on his accordion. Although you know I love Rudy’s polkas. Its just how long we will have to wait in line again, as in forever, to get back “

“Rudy is very good on the accordion,” Diva said loyally, knowing that I was very fond of my ex-boss. He was the one I left the Screwdriver for when I LEGALLY transferred my own grant money from Columbia University, downtown to St. Elsewhere. Long before the Head of the Accounting Department stole 275,000 from my NIH funding and I fled to Oklahoma.

“Anyway, we can get drunk or something,” Diva reminded me. I am sure there will be free beer or wine, it won’t be so bad.”

“it’s already bad,” I said, trying to fluff my hair which was plastered to my head. “Its hot and I’m wilting.”

She started fanning me with her “Meeting at a Glance” booklet. One more bus pulled up, the line moved a little and I spotted Jeremy Irons a few yards ahead in the crowd. Our eyes met. I nodded, wishing my hair looked better. I don’t bear a grudge long.

He smiled and gave me a gracious little wave.

“Hey Diva,” I poked her in the side. “Look. There’s your boyfriend.”

“Things are looking up,” she said. “God is he handsome!”

“Who?” said an English woman behind us. Diva pointed him out. “Oh….you are sooooo right! Delicious!”

“And he has a mellifluous voice like a radio announcer,” I added sardonically.

Another bus rounded the corner. Some people were milling around, breaking the line, greeting and hugging each other like long lost friends which, come to think of it, they probably were.

It was hard to tell who was ahead of who any more. Diva maneuvered us (me, herself and the English lady) in front of a group of Italians who were arguing about something incomprehensible. “At this rate, we will be on a bus in ten minutes,” said Diva. “You can hold out for another ten minutes, can’t you Della?”

“I hope you can,” said Jeremy Irons in his mellifluous voice. “This is going to be a wonderful party.”

He was standing right beside me. Close. How had we gotten so far ahead in the line? Or how had he fallen back so far?

“Do you know about this castle place?” I asked him.

“Yes,” he said. “I have been there before. It is set high on a hill, with a magnificent view of Barcelona. It is one of the most beautiful vistas in the world. I can’t wait to show it to you. And inside the castle, there are hallways filled with Meidevil and Renaissance Art, some of the most exquisite examples of tryptechs that exist, and then there is everything from el Greco to Yanez and Llanos, some of the later paintings have a definite Italian influence, much like Spanish versions of Raphael. And yet so Spanish. You can’t possible take it all in the first time, so I suspect we shall have to return there again and again.

Yes, he really talked like that. I left out most of the six second pauses, though. They were growing on me. He really was a very thoughtful guy.

And what did he mean by “we”? Was it the Royal ‘we?” Or did he think I was a friend of his?

“Oh, yeah, great.” I said softly, perplexed.

He was leaning down towards me to hear me better with that drop dead gorgeous face, and I was finding it a little bit difficult to dislike him. I did feel a little guilty that I was standing between him and Diva, who was making goo goo eyes at him from my other side, and nudging me to get out of her way. But we were all being jostled by the crowd, so it would not have been easy to pull a switch.

Suddenly he was taking my hand. “Let’s run for it,” he said.

He pulled me out of the line, away from the crowd. Three busses were coming around the square. Jeremy and I ran for the third one before the rest of the crowd had finished figuring out how to divide itself into thirds. We integrated ourselves into a flow of people near the front of the third bus, and stood there, waiting for the doors to open. It occurred to me that a very odd thing was going on, we were still holding hands.

A little breeze ruffled his hair. It was just like a movie, where a regular girl gets a date with the most popular boy in school. I felt a guilty thrill of electricity and then I realized that Diva was not there with us. She was still standing there, 50 feet back, where we had been before.

“Come on Diva, over here! “ I yelled. But she just waved me off.

“See you at the Castle, Della,” she called balefully back, looking as confused as I was.

On the bus, he led us past several open seats in the front to where there were two together, and guided me in there. He sat beside me and put his arm along the back of the seat, touching my shoulder for the entire trip, but not in any way where you would know if it was on purpose or not.

The sights of Barcelona passed in a blur outside the tinted glass windows and I thought I should try to remember that tour of the city.

Here is what I remember. Spanish architecture, people walking down the street. People walking up the street. And Jeremy Irons' arm around me.

There I sat, getting vapors from a handsome and attentive man who was asking me polite questions about Oklahoma and the Ardmore Medical Research Foundation, and was waaaaaay outside my dating league. Besides I really had thought he hated me.

The castle was at the top of a steep hill and when we got off the bus Jeremy took my arm again. “I would like to take you to the most beautiful spot in the world,” he said. “With your permission.”

We had to climb about a hundred steep, ruined, stone steps, and he kept his eye on me, steadying my balance from time to time. Whether I needed it or not.

Of course I didn’t need it. But I was wearing Dolce and Gabbana heels , so how would he know that?



The top of the hill looked out in one direction over Barcelona and the port and the Mediterranean, in the other direction was the rest of Spain. The sun was low, and the horizon was turning red. It was as sweeping and romantic as one of those scenes from Lawrence of Arabia or Dr. Zhivago.



And as emotinally evocative as the last scene before the Intermission in Gone with the Wind. You know where Scarlett Ohara says “AS GOD IS MY WITNESS, I”LL NEVER GO HUNGRY AGAIN!!!!!”

And the sky turns orange and the black dirt of Tara trickles between her hands which are raised to the cinemascope vista of the horizon, as the music swells: da DAAAAAAh da Daaaaaaa.



How can you fail to fall instantly in love with a man who has brought you up the magical stairs behind a castle in Spain? And soulfully gazes over the stunning panorama while you can't take your eyes off his handsome, chiseled profile? Even if you don’t like him.



“Wow.” I said.

“That’s exactly what I was thinking,” said Jeremy. “Let’s go see the paintings,now. There are several that I particularly want you to see.”

Who, me?

I was beginning to think this might be a date.

Back in the castle there was already a crush, but the waiters in white tie were diligently passing around an unlimited supply of white wine.

Jeremy picked up a wine glass and swirled it, sniffing at it.

” I can tell this is not from Airén grapes.” he complimented the waiter.

“No senor. “This is Riax Baixas de Galacia.” The waiter bragged.
Jeremy nodded approvingly and handed me a glass. I wondered if we would have had to go thirsty if they had turned out to be Airen grapes.

Then he tucked my arm through his elbow and patted my hand, and I felt a swoosh of erotic longing as we began to tour the paintings, bound together on one side, each holding our glass of wine in the other hand.

A lot of people we knew were noticing us and whispering to each other, was that fun or what?

I did habor a fleeting thought though about what they might actually be saying to each other, such as “the most romantic castle in Spain and the most gorgeous eligible guy in rheumatology and he picks HER?’

The paintings were as fantastic as the view had been. Not that you should take my word for it, take his, he seemed to know what he was talking about. I am a cultural buffoon, having traveled all over the world and seen some of the finest original Art ever created, drunk the best wine, eaten the best food, without the foggiest idea of what any of it was.

But as we strolled with our wine and our linked arms through hallway after hallway of great paintings, even I was blown away by a glorious kaleidoscope of Spanish faces, Mary and Jesus frowning at us, soldiers and Dukes in stiff white ruffs frowning at us, great ladies and their children, all frowning, long, dour el Greco faces crying into their long chins, it was a whirlwind of black eyes, black fringe, black clothes, olive skin, and mantilla covered ladies, haughtily flicking their fans.



















In between drinking my wine, drinking in 300 years of Spanish culture, and drinking in an occasional enraptured gaze at the handsome, intent, gentle face of a brilliant, tragically widowed, gentleman who had chosen inexplicably to hang out with me on that glorious, evocative evening, even if he did try to destroy my rep at a recent Type 2 Ad Board, I also got glimpses of Diva, who had evidently arrived not too far behind us, and seemed to be touring the paintings too.

Or stalking us.

l kept trying to catch her eye as she popped in and out of sight in the milling crowds, gesturing for her to join us, which was not that easy with one arm protectively cradled by Jeremy Irons and the other balancing a glass full of fabulous Spanish wine.

The more I drank, the more full my glass got, that was how magical the evening was. That’s how good the serving staff was, too.

So mostly I was reduced to gesturing at Diva with my chin, since I did not want to risk losing what I had in either one of my hands.

But she insisted on following us at a distance, making silly faces at me. She was pretending to be furious that I had stolen her boyfriend, but of course she made it very clear by her exagerrated gestures that she was joking.

And of course I knew better.

Dinner was in some cavernous hall lined with gigantic tapestries. Jeremy led me to an empty table, away from the main throng of people. It was a great set up for a long, intimate dinner.

What might have happened, I still wonder sometimes, if I had not suddenly developed a case of extreme guilt, excused myself for a minute, run back into the portrait gallery and dragged my best friend Diva and the Englishwoman we had picked up in the bus line back to the table with Jeremy.

Diva protested as I dragged her across the room, saying it was my date,and I had a right to it.

"Don't be silly," I said. "You can date him too, it will be fun."

“OK,” Diva said. “But you are nuts as usual. Did you see the way the way he was looking at you? He loves you!:

“I thought he hated me.”

“Me too. But you never know!”

We all gathered around the table. Diva sat on one side of Jeremy and I was on the other. The Englishwoman sat on the other side of Diva. Nota Petrosian and a couple of his fellows from UCLA showed up to fill up the rest of the table. Diva started making unsubtle handsignals to Nota about me and Jeremy Irons, and he laughed and winked at me.

“These are incredible tapestries,” I said to Jeremy, to get his attention away from my horrible friends.

“I don’t know much about these,” he said, gazing around with appreciation. “But I am guessing that one is probably Andalusian.”

“Yeah and they’re so big,” I murmered. "How did they ever get big enough looms to weave them?"

He smiled at me. “I think they are modern. They have factories here, so unfortunately, although the style is lovely, they are made by machines.”

“Oh,” I said, feeling dumb.

“What kind of wine should we have with dinner?” he changed the subject graciously.

“White wine!” Diva yelled.

“Red wine!” one of Nota’s fellows said. “We are having beef.”

“You don’t need to drink red wine with beef,” Diva scoffed. “And besides I don’t eat meat, speaking of which, what the hell am I going to eat?”

“Well, of course you can drink anything you like,” Jeremy said to the table. "And Diva, we will make sure you get a vegetarian plate."

Then he turned quietly to me. “I recommend the Ossaria reserva." He said in an intimate sotto voice. "I would like to see what you think of it.”

“Sure,” I said.

“Is that reserva stuff white or red?” Diva asked me loudly.

“Uh....”

“It’s a wonderful red wine,” Jeremy smoothly interjected, turning to her politely, "...but let me also recommend something you might like...I think maybe....this one...."

“Say,” said Diva leaning over and grabbing Jeremy's arm before he could turn back to me. “I hear your daughter is a swimmer.”

“Why, that’s right,” he said, sounding pleased and gratified. “She just got her national ranking.”

“My daughter is a Badger!” Diva bragged.

“Really? From New Rochelle?”

“How did you know about the Badgers?” I asked him. The Badgers is all Diva ever talks about during the swim meet season.

“Everybody knows about the Badgers,” Jeremy laughed at me smugly, making me feel left out.

Have you ever eaten dinner with two people whose daughters are serious high school swimmers? Don’t.

For the rest of the evening, the date went to Diva. Once the topic of swimming was broached, the two of them zeroed in on each other with all of their body language as if there was no one else at the table. For a while I tried to listen to them intently discussing the relative difficulty of three hundred meters and five hundred meters and what kind of flip turns are optimal and whether it is better to be the best in the worst league or the worst in the best league...

I would have been a little more impressed with her prowess if there had been an ounce of flirtation in Diva’s manner to him, or but it wasn’t like that at all. They were behaving like two Stage Mothers, sparring with their daughters for swords, each pretending to compliment each other's kid while finding a way to slip in something to point out about their own daughter's superiority, and trying to wheedle from each other the real skinny on every statistic and every swim meet the other kid had been to as if to scope out how formidable the competition might be eventually at the Olympics.

Diva and I still argue to this day about whether her half of the evening counts as a real date or not.

Meanwhile, as it became increasingly clear that I would not qualify even as a secondary hanger on in that conversation, I gave up on them and turned to Nota and his fellows, but they were rapidly becoming drunk and silly. The fellows were all under thirty and telling jokes I did not understand, using slang words I did not understand.

The Englishwoman had found some other friends and disappeared. I ordered a glass of white wine and drank it. Then I went to the bathroom, checking out the other tables to see who else was around. I sat down with some friends from Pittsburgh for a while and had another glass of some kind of red wine, not sure what it was, but if it was Ossaria reserva it wasn’t all that good.

Of course we cannot be certain that I would have had that opinion if it was still being ordered for me by the handsomest man in Rheumatology.

Eventually I found myself up on the stage drunkenly dancing the polka with a very tall, stiff Swede, while my ex boss accompanied us on his accordion. The whole room under the giant tapestries was applauding and cheering us except for Jeremy and Diva, who were still bent close together at their empty table....

Jeremy Irons got married about a year after that to a very nice woman who works for Pfizer. Nobody that gorgeous and romantic was going to go floundering around the academic circuit having fantasy dates with squirrely lupus ladies for very long, anyway. Diva and I forgave each other immediately for stealing him away from each other that night, especially since we both knew the whole thing was some kind of a warp in real time.

He could not possibly have kept up that level of romantic intensity with me anyway in the cold light of day. We were bound to start some lethal argument about the BILAG before too long. Which of course did happen, the next time we were at an Ad Board together.

But just in case he really is like that in real life, his wife is very lucky! And I don’t envy her! That was one exhausting evening.

Fast forward to a late afternoon a number of years later when I had heard that my two abstracts on failed clinical trials were accepted for two big talks at the ACR meeting. Diva was on her way to the airport in San Francisco, and I was in Dallas with several good hours left before I had to leave for my short evening flight to Oklahoma. There was time enough to shop for a suit.

I went across the street to Dillards to see what designer label I could fit into.

For comparative purposes, I would guess I was probably at least 20 pounds heavier than I had been that night in the castle in Spain.

But I was feeling cautiously optimistic and wearing my Spanx, so I tried on a size 12 Liz Claiborne pant suit. Liz Claiborne clothes are larger than some of the others.

I couldn’t even get the pants up over my upper thighs. And the jacket would not close in front. Gosh, I thought. I must be really be a 14 now.

So I tried on a size 14 Alfani. I could pull on the skirt all the way if I squeezed a little, but the zipper couldn’t even get off the launching pad. The jacket would close if I pulled it hard enough, but not all the way to the buttons.

What was I, a size 16? Yipes!

Queasily, I tried on a size 16 Jones New York jacket, and it looked terrific. Very cute. And I didn’t look fat at all in it. I am one of those fortunate people who doesn’t usually look quite as fat as I really am. If my clothes fit. Unless I lose a substantial amount of weight.

Feeling a little better about everything, I asked the saleslady for the matching skirt but she told me the skirts in that line only went up to size 14. She suggested I try a 1X in the LARGER WOMAN’S department.

"That might be more comfortable for you anyway, sweetheart," she suggested, giving me a little wink.

Demoralized, I walked away. I knew I could have worn that Jones New York jacket with some other random skirt if only Diva would not kill me.

I was about to leave the store, so I could get back to the hotel in time to have a good cry before packing up, but I saw a larger looking suit on a rack by the escalator. It was incredibly ugly, in some kind of awful knit (as opposed to the body-skimming black knit pants and Misook jackets which are the centerpieces of my practical, wrinkleproof, bulkless travel wardrobe). This, however, was a knit suit.

Do not EVER buy a knit suit. Unless you weigh about 90 pounds and have no taste. If you are larger than a ten they are guaranteed to make you look twenty pounds heavier than you really are.

And they are all ugly anyway.

The word knit does not fit with the word suit.

But I checked out that section of the store anyway, thinking there might be something better in my size.

“Can I help you, doll?” came a gravelly voice with a Bronx accent.

“I’m not sure,” I said. “I’m looking for a suit, but I am apparently too fat. The only thing that seems to fit is size 16.”

“I can fix you up, doll,” she said, eyeing me appraisingly. Her breath smelled like cigarettes. “I have some sweet little numbers back there. Size 14. My suits will fit you. And you will find they are very attractive. And very slimming.”

“Are they knits?” I said. “I don’t want a knit suit, this is for a professional meeting.”

“Are they knits?” she repeated, appalled. “Would I bring you regular knits at your size?”

“You won’t?” I let her lead me down a crowded hallway into a small dressing room.

“These are high end knits, doll. It’s not what you think. Here, let me take your jacket.”

She disappeared with my jacket. I took my clunky shoes off.

“Here you are, doll.” She had three suits with her, and they were, actually, very pretty. Almost but not quite like knits.

I was not sure that Diva would like them, though, so I hesitated.

“These are high end knits,” she said again. “It’s not what you think. And, they are all size 14. You are definitely a size 14.”

“Do you have any size 16?” I asked.

“Well, we don’t go that large,” she admitted. “But we don’t need to, these are going to fit you like a glove.”

I waited until she left the room, firmly latched the door, and examined the price tags. Wow. One of them was $1,024, one was $994 and the other $1,294. I lined them up in reverse price order and slipped out of my functional black travel pants, laying them over the back of a chair.

The skirt went on easily, but there was no mirror in the room. What kind of dressing room was this? I tried on the jacket and it was a perfect fit. I stretched and leaned and sat in the chair, and nothing bad happened.

“I am a size fourteen!” I sang out gratefully.

On the other hand the jacket was a little short, and I worried about that. In general, I don’t look good in short jackets. Still you never know. I once had a short jacket that looked terrific on me.

“Of course that was about twenty pounds ago,” I muttered to myself.

“Ready, doll?” the saleslady called. “Come out and take a look at yourself!”

She pushed my door open even though I thought I had locked it. She stopped when she saw me, and then gave me a big happy smile.

“Gorgeous! Come out and take a look at yourself! And let me get these out of your way,” she cooed, scooping up my pants.

“No thanks," I said, nervously. "I’ll keep my own clothes. And can you bring my jacket back, please?”

She had already left the room with my pants. I followed her and ran right into a full length three way mirror.

OUCH.

The jacket was just long enough to accentuate my big butt, and the skirt was riding up on my thighs, and bunching under my belly. I looked awful.

“I look awful,” I said. “I look fat!”

“Let me bring you a pair of heels,” she fluttered. “You should never look at yourself in a suit without heels on.”

She disappeared into the store. I looked around for my clothes and could not find them. Where could my pants be? She had been in plain site the entire time.

Was she a witch? Resignedly, I went back in the dressing room to try on the second suit.

“Here are some heels for you to use,” she called, barging into my room again, before I had the skirt pulled up. This time I was one hundred percent sure that I had locked the latch.

Either she was a witch or the latch was broken. Or both.

“Here let me help you with that zipper,” she said, reaching for my back with her claw-like hands.

“That’s OK, I have it,” I said quickly, stepping away from her and zipping it myself. The skirt seemed to zip up a little looser around the belly than the first one, although it was still tight around the butt. And the jacket was longer than the first one. And I had to admit it was a beautiful material. I loved the material.

“Uh….I will look at this one in the mirror, and can I have my clothes back now? I asked her.

“Of course you can, doll," she soothed. “Put first put on the heels, I insist. It will completely change how you feel in this suit.”

I slipped my feet into the shoes which were several sizes too big, and wobbled out of the room like Minnie Mouse.

My legs looked great in the heels, I have great legs. The Knit suit had ugly broad shoulders, was too wide on top and bunched around my thighs, creating two huge elephant humps. It was the most hideous view of myself I had ever seen. But then again, (I was forced to admit with a sinking heart), this might be the fattest I had ever been.

‘WHERE ARE MY CLOTHES?????” I screamed at the witch.

“OK, OK,” she pouted, opening a drawer in the wall. “You don’t have to get an attitude.”

I looked at my watch while leaving the store, and figured that Diva must be on the plane waiting nervously to take off. I crossed the street and sat down in the lobby of my hotel to call her.

I just wanted to talk to my best friend. And I knew that if she was on a plane she would be feeling the same way.

I was crying so hysterically by the time she said hello that it was hard to explain about the saleswoman from the Bronx bringing $1,000 designer knits in size 14 that made me look fat.”

“So get a sixteen.” said Diva briskly. “Wait a minute, did you say knit?”

“I think she was the knit saleslady, and she had me trapped in there, and then she ran off with my clothes.” I sobbed brokenly.

"Get the hell out of there, with or without your clothes, I will handle everything for you when I get home!" shouted Diva.

That is if I get home alive,” she amended herself.

And I knew that she would.

Here is a sample of the many flurried phone calls going back and forth every 10 or 15 minutes between Diva and me the next day. I was in my clinic in Oklahoma with 15 lupus patients, and she was in Lord and Taylor on 34th St and Lexington Avenue, neglecting her three overdue textbook chapters and a large stack of grant applications she was supposed to review.

Diva to Della: "I don't believe you are a size 14. That's ridiculous."

Della: "Well they were knits. You can’t really tell with knits. They stretch."

Diva: “I didn't mean it that way. I am guessing you are a 12 at the worst.”

Della: “Listen to me, Diva. I only looked good in a Jones New York size 16, and nothing else that I tried on in that entire store fit.”

Diva: “What were the brands you were trying on? Were you trying on all low end brands like Jones? You know they run little in those brands.”

Della: “It was not Jones, it was Jones New York. That’s not low end.”

Diva: “We can do better than that. If only I was sure of your size.”

“I know what,” I suggested, “Ask Martha what size she is. I am sure I would fit into her clothes now."

“Good idea,” said Diva. I will call her right now.

Martha used to weigh at least 40 pounds more than me, but she had been going to the gym and I had been....traveling a lot.

Diva (calling back) “She says she is a 14 in a jacket. She wouldn't tell me her skirt size.“

Della: “See? Martha and I are both 16 in a skirt, I told you!”

Diva:” I don't believe it. You have to be wrong. No way. You are not that fat. And (loyally) neither is Martha!”

Della: “Yes I am. I really am that fat. I am going on a crash diet.”

Diva: “Good, then I will get you a 14?”

Della: “Absolutely not! What if I plateau before my talks?”

Diva: “Trust me, I am looking at the really top end suits for you. These run much larger.”

We hung up and I went into Room 4 to see a new patient. She was an 18 year old of mixed African and Caucasian descent, tall and slender, pretty enough to be a model, except for the dark disc shaped lesions on her cheeks and forhead and the open sores on the side of her head, which were raised, red, weeping yellow fluid, and scarring up at the sides so that no hair was likely to grow back there.

We talked for a while and I learned that she was a senior in high school, her mom died of lupus when she was thirteen, and she hoped to become a nurse. She had seen the first few spots of this discoid rash come out about six months ago and it just kept getting worse. It was not responding at all to hydroxychloroquine or low dose steroids.

In the last month or so she had been waking up with painful joints in her hands, wrists, shoulders and knees. There were sores on the roof of her mouth. She was so tired that she got short of breath climbing one flight of stairs in school. A boy she had a crush on at school had called her ugly the other day. My phone was ringing.

“Excuse me,” I said to my patient, and stepped out of the room. It was Diva, calling me back.

“OK, I found this really nice woman shopping here. "Say hi."

"Hi!" I called out.

Another voice called "Hi" throught the phone and giggled.

"She is about the same size as you," continued Diva, "...and I have been trying some suits on her. So here is our question. Would you mind if the jacket flops out a little over your butt?”

“Well, how does that look on her?”

A piece of paper was inserted briskly between me and my phone. “Dr. Sugar, can you sign this?” One of the Medical Assistants had an order for an abdominal sonogram that I had asked him to set up for my last patient. I signed it.

“Actually I think it’s kind of sexy,” said Diva. “I mean her butt is sticking out just a little, but it works. And its a beautiful suit. It’s an Ellen Tracey. These brands always make them bigger. I am getting you this one. It's a 14.”

“No! No! Get the 16!" I screamed. “I don't want the seams to rip in front of 2,000 people when I climb the stairs to the podium!”

“You are nuts,” said Diva cheerfully. Then, sotto voice, “Her butt is MUCH bigger than yours and she is wearing a 14. "

“You have no idea how big my butt is. I am very clever at hiding just how fat I am. With my stretchy black travel pants and the long sweaters that you hate!”

Suddenly Diva was yelling, “Hey! Hey! Where are you going?” I heard a scuffle.

“SHIT! She is going to buy the suit,” Diva yelped.

"So what, get another one for me," I laughed.

“You don't understand, that was the only 14 in the store! I have to get it back, talk to you later!”

Click.

I went back to my patient. She had been crying.

“What has anyone told you about lupus?” I asked her.

“That my immune system….”

I handed her a box of Kleenex.

“What about your immune system?” I asked her.

“Attacking me.” She sniffed.

“Well you know what?” I said, sitting down on the stool next to the exam table where her feet were dangling in adorable little ballet slippers with roses on them, “Nothing could be further from the truth….”