Lea Sewell had always thought when she was growing up that she would wind up in biology. But two decades ago, as an undergraduate at Dartmouth, working in the lab of a senior researcher, she noticed how much time was taken up with writing grants and how long it took to get results. "I think I wanted more successes every week, not two or three a year for a lifetime."

More and more after that Sewell thought of becoming a doctor.

She remembers walking around the Dartmouth campus one snowy afternoon trying to decide what to do. "I thought, 'Can you be a woman and a wife and mother and a doc?' That was my only question. Because I was unwilling to give that up. And I said, 'Yes, I can do that.'"

Yet laboratory science still intrigued her. During medical school at Duke in the early eighties, she spent enough time in the lab to become fascinated with the remarkable new developments in immunology. One of the attractions of rheumatology, for her, was that it meant grappling with the newly discovered complexities of the immune system. As Sewell's friend and colleague Martha Barnett notes, medical specialties are arrayed along a continuum. "People are either more interventional or more cognitive." Surgery is at the interventional extreme of the continuum. If you choose rheumatology, where the immune system is your territory and where the answers tend to be complex and incomplete, you have chosen the cognitive end.

Sewell's current position, part researcher, part staff physician, is an ideal melding of her scientific interests and her wish to take care of patients. What she does is sometimes called "translational" research, because it provides a bridge between basic science and clinical application. But even though she likes the niche she's in, Lea Sewell is often unhappy on the job. In fact, it sometimes seems as if there are two Dr. Sewells. When she is seeing patients, Lea Sewell couldn't be more sympathetic and patient. When she squeezes a joint and the patient winces, Sewell says, "sorry." But when she's dealing with colleagues and with the bureaucracy, Sewell is often impatient and enraged. Like most doctors these days, she must spend a lot of time thinking about how to justify the cost of what she does. And she thinks the system undervalues doctors in general, and clinical research in particular.

Right now, Sewell laments, doctors are "viewed as a cost center not a profit center" in the organization, even though they are the "cash cows." Physicians, she complains, are under constant pressure to justify all their costs. But no one gives praise or credit for what they do to ensure the quality of care. "There's no one saying, 'Oh, you did a good job, you got an X ray for that patient.' There's only the negative."

The only thing that gives Sewell some autonomy and fiscal clout within the increasingly burdensome bureaucracy is clinical research. The amount of money paid by drug companies to clinical research sites is a closely held secret. Jo Ann Wallace, of AutoImmune, refuses to divulge any figures. One reason for this is that the payment, which is made on a per-patient basis, varies from one place to the next. "The range," Wallace acknowledges, "is huge." Companies don't want one site to know what the other's getting. According to a 1999 report on clinical trials in the New York Times, the payment to sites can range from $1,000 to $4,410 per patient. The drug company, according to Lea Sewell, "has a maximum in mind, and will not use a clinical site if they go over that number." But there are factors that raise the value of a site in the company's eyes. A "thought leader" like Harvard can demand more. It also helps if the investigator is considered to be a "good enroller," particularly if the disease in question is rare, or if previous studies have depleted potential candidates.

Lea Sewell, situated at a Harvard teaching hospital that is a magnet for patients with unusual diseases, manages to attract a lot of drug company research at a decent per-patient fee. Even after she pays out a large percentage of the money to cover office space, laboratory, and administrative costs, Sewell manages to support a part-time research nurse and to augment her own salary from her clinical research. That is why it is important to have a successful meeting, on this day, about the new Amgen trial.

The Amgen representative is sitting in a corner of the crowded research office, chatting with Michelle Finell, when Sewell arrives. She has come from Amgen's headquarters in California to look at a number of sites in the New England area, and discusses the entry requirements for the fifty-two week trial with Sewell and Finell. They have some questions and suggestions for her, which she promises to take back to headquarters. Then she asks for the customary tour of the facilities where the trial will take place.

The Amgen representative is young, with a B.A. in psychology and limited experience at her job, but Sewell and Finell, who might be annoyed with her under other circumstances, treat this particular neophyte well. They devote perhaps an hour to giving her a tour. She takes careful notes, and they show her two labs on different floors in the hospital, walk her past radiology, then take her up to the research unit, a floor of the hospital where patients with severe RA are involved in an inpatient test of a new drug. They introduce her to the pharmacist, and show her the pharmacy from which trial drugs are dispensed. Then, because she is required to see every space used in the trial, they walk with her over to the building where Sewell has her rheumatology practice and show her those labs and offices as well. Before the rep leaves, Sewell and Finell have what they want: a tentative date in September for the pre-trial investigator meeting in Arizona, and enough information on the requirements and exclusion criteria to begin looking for candidates for Amgen's phase-3 trial of a new arthritis drug called Anakinra.