Dr. Carole Dorsch: She likes puzzles

Dr. Dorsch

Until she was two, Carole, her parents, and her father’s older brother lived together in her paternal grandmother’s neat row home on North Broadway in Baltimore, just up the road, the boulevard, from Johns Hopkins Hospital. After that, her parents bought a place “down the shore” in Essex-Middle River on an estuary of the Chesapeake Bay. It was just 12 miles from the city but seemed “so far away” to the little girl. So, Dr. Carole Dorsch and her younger sister Beatrice grew up playing on the water. 

Carole’s father, Oscar, did electrical work for Standard Oil during the Great Depression and was an aircraft inspector for the Navy during WWII. He was a bit of a pseudo-entrepreneur, said Carole, and after the War, he continued to work as an electrician and bought a number of rental properties. Her mother left high school to take a job in a factory and then worked as a beautician, running her own shop.

But her father had a “midlife crisis” when Dr. Dorsch was in the second grade; he wanted to enjoy life. So he stopped working, planted flowers, raised birds, and began careful investing in the stock market (and he was quite good at it). This was okay for a number of years, but when his first daughter decided on her own in the eighth or ninth grade that she wanted to go to college Oscar realized that he needed to do something else to make that happen. 

He liked working on his own, doing everything himself, and not delegating tasks to others. So he purchased one of the earliest franchised drive-in fast food and ice cream restaurants, a “Twin Kiss.” Carole said that her parents “toiled away” from morning to night running the place on Bel Air Road. She worked there when she could, even while in medical school. When the restaurant shuttered for the winter, the family sold Christmas trees. Later on, after Carole finished medical school in 1968, her father turned the restaurant into a liquor store (that was sold shortly before he died of cancer).

Vintage photo of Ken and Jean Witmer's drive-in walk-up "Twin Kiss"
ice cream and sandwich restaurant in Palmyra, PA

Her father had told her (and Carole choked up as she recalled this for me) that when he stood on the corner of Monument and Broadway, the location of the iconic Johns Hopkins Hospital, selling newspapers, he never had a thought that his daughter would one day graduate from there. 

Dentist or Doctor?

Anyway, Carole’s interest in science, in how things worked, in how they were put together, was a driving force for her as she was in school.  But being a doctor was not her initial plan. You see, she had “terrible teeth” and was “always at the dentist’s” and she thought she would be a dentist. (Her family doctor, it turns out, wasn’t really the best role model; he smoked  cigarettes while he examined her, even though he had part of a lung removed to treat tuberculosis!)

So she carefully carved a bar of soap into teeth and took the dental aptitude test. She was all set. Until her father, who rarely offered advice, said, “I'd rather you be a doctor than a dentist.” She listened, bought a small anatomy book, and shared her new excitement with her mother.

While attending Kenwood High School she studied piano at Peabody Preparatory. She recalled that on the way to her lessons the bus passed by Hopkins and she saw the medical students “floating around” in their short white coats. She said that “there were sheep” just east of the hospital since Dr. Manfred Mayer needed their red blood cells for his work on complement (an essential part of the body’s complex defense mechanism, the immune system, a system that sometimes betrays us, as we will see later). 

Postcard depicting the Peabody Institute in Baltimore 

On to College

At Kenwood, she had a “wonderful teacher of American history” who had gone to Hopkins. He told her that if she was thinking of all-male (until 1970) Hopkins she should consider Goucher College in Towson. She did, and Carole, the budding scientist, entered the all-women’s school as a biology major but later switched to chemistry. 

She did a lot of lab stuff at Goucher. She especially enjoyed genetics and embryology, and as a member of the Biology Club, she went down to Hopkins to listen to Dr. Victor McKusick (the “father of medical genetics”) as he gave brilliant evening sessions. And as a (promising) “Goucher girl” she was picked to work with the “wonderful” gastroenterologist Dr. Frank Iber in his lab for two summers (while also doing her part at the family’s busy restaurant).

“The story of my life,” said Carole, ”is that I ran into a lot of really nice people who helped me along the way.” (She really did.)

Anyway, as she liked the basic science and the lab work, she wavered between going to graduate school for a Ph.D. and a career in medicine. Her “prim” unmarried chemistry advisor at Goucher was also the medical school advisor and after Carole decided on medicine she was given advice for her critical upcoming interviews. 

So, for the University of Pennsylvania grilling, she wore (wait for this...) a Jackie Kennedy-style pillbox hat and pristine white gloves. The session went well but, in time, the interviewer “was concentrated on what would happen” if she got married, was she worth it?  That is, would she practice medicine for only a few years and thereby waste a valuable space that could have been filled by a man with a longer career? 

January 21, 1961 (from theprojectsworld.com)

The admissions interview at Johns Hopkins was different. Dr. Tommy Turner, the Dean, let Carole know that (somehow) Dr. Iber had already told him “very nice things” about her. For the illustrious Dr. Turner, intelligence, brainpower, was the most important criterion for admission, not who you were, or what race, religion, or sex. Carole was accepted.

While still at Goucher she did carbohydrate studies “hydrolyzing mucopolysaccharides” with Suzanne Brownlee from Duke for her senior thesis. And with that connection, and her “travel lust,” she spent the summer before medical school on the Durham campus working with Dr. Bob Wheat. She was able to get, in 1965, her first scientific publication: the one-page work titled (Dr. Dorsch had to think for just a second) “The occurrence of pyruvic acid in the capsular polysaccharide of Klebsiella rhinoscleromatis.”  (More than 30 papers in peer-review journals would follow.) 

Dr. Dorsch's first published paper

Medical School

So Carole immersed herself in medicine at Hopkins in East Baltimore from 1964 to 1968; there were nine women in her class (compared to only one or two in the classes just before and after hers). She recalled this was during the height of the civil rights movement and she was a witness to the terribly destructive riots that followed Rev. Martin Luther King Jr.'s shocking assassination by James Earl Ray on April 4, 1968, at the Lorraine Motel in Memphis. 

(Later on, when Carole was in Memphis during one of her travels, she visited the iconic motel, once faded, and since 1991 reborn as “The National Civil Rights Museum.”)  

During the rioting mayhem, and at the request of then-Governor Spiro Agnew, there were National Guardsmen with rifles stationed every twenty feet along Broadway, she said. Carole was visiting friends on Monument Street and  watched in horror as “North Avenue was in flames.”  More than 10,000 troops were deployed and over a thousand fires were set.

Fire on Gay Street in Baltimore on April 6, 1968 (from the AP)

While in medical school, she continued to “do a lot of lab stuff” with the “connective tissue” division. She worked with organic solvents and (“brand new”) antinuclear antibodies and their so-called staining patterns for diagnosis). She presented a paper at a rheumatology meeting in Cincinnati in the middle of winter (after her first plane flight). When the effort from a mere student was criticized, she received moral support from the chair of the session, Dr. Eugene Barnett, from Rochester. 

She didn’t wither and continued to do basic research. One summer she worked with chicken embryos at the Carnegie Embryology Lab and another one of her projects involved trying to isolate basophils, the hard-to-find white blood cells associated with allergies. 

The Johns Hopkins medical school class of 1968
 (Young Carole is third from the left in the front row.)

Internship and Residency 

When it was time to choose a career path, Dr. Dorsch decided on Internal Medicine. She applied to Vanderbilt, Hopkins, and a few other places for her internship and one-year residency through the new match program, intended to pair applicants to hospital positions equitably. But the department chairman at Hopkins, Dr. McGehee (“Mack”) Harvey, called Carole himself to offer her a spot (outside of the match, maybe not quite Kosher) on the prestigious Osler Service.  She couldn’t say no. 

On Osler, you worked hard, often through the night and the next day, with only one day off a week. She said that you took every tenth admission and followed 10-15 patients in the hospital at one time. There was no ICU (imagine that!) and very limited ancillary help, so you did almost everything yourself.  You learned medicine by taking care of patients day after day.  

Intern presenting a patient during Grand Rounds in Hurd Hall Hopkins (c. 1950s)  

She had not decided what to do after completing the two years at Hopkins when she “ran into” the masterful clinician, teacher, mentor, and diagnostician Dr. Philip Tumulty in the school cafeteria.  After they talked about her career, he told Carole that, since she liked to experience different things and had thought about UCLA for a third year of internal medicine training, he would gladly make a call to one of his colleagues there to facilitate that.

Los Angeles and Back to Baltimore

During a break in her studies, Dr. Dorsch had decided to take her mother to Europe for three weeks. While waiting in the old BWI airport (Friendship International), she opened a letter from UCLA. They offered her a third-year postgraduate position.  She quickly raced around the terminal to find stationery to send the reply. So she went to California.

Her first specialty rotation in the sun was rheumatology.  She quite enjoyed solving the “puzzles” of the patients who had “connective tissue diseases” or, more accurately, autoimmune disorders like lupus or rheumatoid arthritis. Dr. Barnett (who, you may recall, had come to her rescue at the meeting noted above) had moved to UCLA from Rochester by then. He saw her talent and wanted her for his program. (The specialty of rheumatology was relatively new as there was no board certification until 1971 and no accredited fellowships until 1987.) 

"Mary Betty" (ACP)

Carole liked L.A., took the fellowship, and stayed on the West Coast for a total of four years. She was lured back to Baltimore in 1974 by (the imposing) Dr. Mary Betty Stevens as Dr. Stevens took over the running of the Connective Tissue division.  (She was the first woman to head a division of medicine at Hopkins.)

(Speaking of strong women, here's an interesting tidbit later shared with me by Dr. Dorsch. After the hospital was built from the large estate left for this purpose by merchant and banker Johns Hopkins, there weren't enough funds to build the medical school. Four daughters of the original trustees offered to raise the needed money, but only if the school admitted women. And so it did, when it opened in 1893. In fact, writer Gertrude Stein, who studied psychology with William James, was in the class of 1901. But she didn't receive a degree, possibly due, in part,  to William Osler's known tendency to misogyny--nobody's perfect.)  

The expanding group of rheumatologists was based at Good Samaritan Hospital, away from the main Hopkins campus, and Dr. Dorsch was to be the lab person on the small team. Among other things, she continued her important work on autoantibodies.

Antibodies and Immunity

A few words about antibodies and immunity are needed for our review. The exceedingly complex immune system (rivaling the complexity of the nervous system) evolved to protect us from injury. To heal wounds. To repel dangerous microbial invaders. To find and eliminate cells that have mutated and might grow into widely spreading cancers. To allow us to survive long enough to reproduce. 

But sometimes things go wrong. Microbes block our defenses or even hide deep inside our cells. Cancers figure out ways to actually turn off the immune attack. And sometimes the system misfires and mistakenly rebels against our own tissues (the self) as if they are foreign (the other).  The autoantibodies so produced are the cause of many diseases. This includes, for instance,  type 1 diabetes, the commonest thyroid problems, gluten sensitivity and celiac disease, multiple sclerosis, rheumatoid arthritis, psoriasis, and many other conditions, including the prototype autoimmune disease, systemic lupus erythematosis. Dr. Dorsch often took care of people (mostly young women, by far) who had or were suspected of having this complex autoimmune disorder. 

Lupus

Systemic lupus, by the way, was first clearly described by…(any guesses?)...none other than the aforementioned towering figure Sir William Osler, the Canadian general internist who became the father of modern American medicine. As the first physician-in-chief at Hopkins, he was the originator of bedside teaching of medical students, and the inventor of the house officer model of training.    

Osler contemplating a patient at Hopkins
(from National Library of Medicine)

So, let's take a short journey into the stuff of lupus. According to an article on Medscape, systemic lupus erythematosis is “a chronic inflammatory disease that can affect almost any organ system, although it mainly involves the skin, joints, kidneys, blood cells, and nervous system. Its presentation and course are highly variable, ranging from indolent to fulminant.” 

It may be notoriously difficult to pick up in the early stages since the symptoms may be very vague. And it can mimic other diseases, diseases that are organ-specific. So Carole, using the acquired Oslerian skills of active listening, careful observation, and meticulous examination, diagnosed and treated many patients (mostly women) that confounded the non-rheumatologist specialists. (And, thereby the saying: “If you don’t know what they have, send them to a rheumatologist.”)

In lupus, there is a loss of B-cell tolerance and recognition of self-antigens. The B cells (that we learned about early in the Covid-19 pandemic) originate in the bone marrow (hence, the “B” as opposed to "T" cells related to the thymus gland in the chest). They mature into plasma cells that produce antibodies. 

There is a slew (maybe more than 100!) of such antibodies against various cellular components (especially debris from degenerated cells) found in individuals with lupus in addition to the diagnostic double-stranded DNA antinuclear antibody. And these different antibodies may affect different tissues in different ways. 

(Antibodies directed against the NMDA glutamate receptors in the brain, for example, are involved in some of the neuropsychiatric syndromes reviewed in one of Dr. Dorsch's writings with the Hopkins group.)  

Trying to limit inflammation and damage with non-steroidal drugs and antimalarials and suppressing the immune system generally with steroids or chemotherapeutic medications were the only treatment options throughout Dr. Dorsch’s career as a physician. There were often troublesome side effects and many treatment failures. 

Targeted therapy for lupus became available in 2011 with the approval of belimumab (the first drug approved for lupus since hydroxychloroquine...in 1955!). This monoclonal antibody (“-mab”)  blocks the B-lymphocyte stimulating factor (BLyS) that increases the survival and growth of autoreactive B cells and decreases self-tolerance. It is helpful when other treatments have failed, but only to a degree.

Cartoon depicting the mechanism of belimumab (from ASCPT)

Back to Maryland for a While, Then Florida  

At Hopkins, Dr. Dorsch and her colleagues were productive, producing paper after paper while seeing patients and teaching students. But things were slowly changing (as they always do).  Carole applied for research grants to support the work, but funding was often lacking. Hopkins Rheumatology had joined up with the University of Maryland group. Dr. Harvey retired and Dr. McKusick took over as department head. The teaching became routine and uninspiring. And as Carole “did a lot of work without recognition” she looked to move on. 

One of her rheumatology friends from L.A. had a private practice in Pensacola and needed help. Dr. Dorsch liked the idea of doing her own thing, of being her own boss, and she left the Mid-Atlantic for the Florida Panhandle in 1982. She was busy, but as she had to take turns admitting general medical patients from the ER she was too busy. There were no students or residents, and she found that she sorely missed teaching. And she and her friend eventually “did not get along.” (Her father had warned her to “never to go into business with a friend.”) What would she do next?

From Florida to Pennsylvania

She was at an American College of Rheumatology meeting “somewhere” and was sitting at a bar with a colleague she knew from the joint program with the University of Maryland, Dr. J. Wolfe Blotzer. It just happened that Wolfe was looking for someone to join his practice at the York Hospital. There would be residents and students to teach, and she would do only rheumatology. It sounded better than what she was doing with her friend. So Carole came to South Central Pennsylvania in 1988 for career #3.

By the early 1990s, their private practice had grown to the point that they needed another physician. But financial constraints made it difficult to recruit someone. And the business of medicine, overall, was changing, as hospitals started acquiring practices and employing physicians. 

The York Hospital’s first hired physician was Dr. Francine Camitta, an endocrinologist and diabetologist. Dr. Dorsch was the second (she was naive and simply handed the hospital her practice). They moved Carole around a few times, but she enjoyed the patients, the teaching, and the camaraderie of fellow physicians, and she was happy for a good while.      

But nothing stays the same, and as the “medical group” of primary and specialty practices became larger and larger there were more and more rules and regulations. Office managers were put in place to make sure the dictates were followed, however arbitrary. While some managers were “wonderful,” others were not so much, and could even hurt the practice. 

In addition, the hiring of hospitalists meant that Carole and her partners would stop admitting their patients to the hospital and would focus on outpatient work. Eventually, she lost contact with other doctors and felt “lonely and isolated,” she told me. On a whim, she attended a course in Philadelphia where they talked about other things doctors could do besides seeing patients.

After Years of Practice in York, A Rewarding Teaching Career

Soon after, an ad in the local paper caught her attention: the Harrisburg Area Community College (HACC) was looking for adjunct faculty to teach science to nursing students in Lancaster. She taught her first summer class in anatomy and physiology in 2002 and kept going. She was still in practice then and as she finished in the office and ran to evening sessions twice a week during the year, she “loved it.”   

Harrisburg Area Community College, York campus (from HACC)

A HACC York campus was set up in 2005 and Dr. Carole Dorsch was hired as the first faculty member. Over time, the staff grew “tremendously.” Teaching, she said, gave her a chance to “re-learn basic biology,” to, for example, learn about cell membranes and transport systems, to learn how things work. She was “quite happy” at HACC. She taught full-time for 11 years, for a total of 14 years with the community college. When she finally left the school in 2018 it, too, had changed.

In Retirement

In her retirement, as she looked forward to more travel, Dr. Dorsch has had a battle with her own immune system. Years ago, she was found to have what’s called a monoclonal gammopathy of uncertain significance (MGUS). A clone of one of her B cells was producing a single useless immune globulin in excessive amounts. There were no symptoms, but Dr. Dorsch knew that this could turn into a more serious bone marrow disorder, multiple myeloma, a cancer of the antibody-producing plasma cells. And so it did, not too long ago. The therapy for this has been complicated by neuropathy with numbness of her feet and weakness of her legs. She is improving slowly.

Outside of medicine, Dr. Dorsch especially enjoys travel and seeing something new. She likes to read, of course, but she said that she also likes to cook and has “more cookbooks than medical books.” A recent interest is that of piecing together jigsaw puzzles. She discovered this while sitting patiently in the courthouse waiting to be called for jury duty; she was looking for something to occupy her ever-curious mind when she found a puzzle on a small table. 

And, after four varied careers in medicine, mindfully putting the pieces of the cardboard puzzle together, and finding where they fit, where they belonged, was oddly satisfying. And it mirrored exactly what she did for her patients as a specialist in complicated immunologic rheumatologic diseases. 

And it is hoped that as her plasma cell cancer (that she strongly suspects was the result of work with organic solvents years ago) is kept in check she will be able to continue her travels, either just down the road or much farther away.

References and Readings:

1. Bartels, Christie. MD, MS. "Systemic Lupus Erythematosis." Medscape Nov 11, 2022. 

2. Fineglass, E.J., Arnett, F.C., Dorsch, C.A., Zizic, T.M., and Stevens, M.B.  "Neuropsychiatric manifestations of systemic lupus erythematosis, clinical spectrum, and relationship to other feature of the disease." Medicine (Baltimore)  1976, 55: 323-339. (My husband said he relied on this article when he was a medical resident seeing patients with lupus.)

3. Richtel, Matt. An Elegant Defense: The extraordinary new science of the immune system; A tale told in four lives. Harper Collins/William Morrow, New York, 2019. (Popular story-telling account of immunity; an enjoyable easy but informative read.)

By SC

Anita Cherry 4/30/23