In my last entry, I asked the question "Where are today's Leonardos?" in the allergy community. If I was the head of an allergy training program in a University (which thankfully I am NOT), I would not only (of course) emphasize superior critical analysis and clinical problem solving, but also very unconventional creative thinking sessions among all trainees. Why? Because I firmly believe that the clinical triad of a superior allergist is technical knowledge (i.e., thoroughly knowing disease states we deal with), wisdom (which comes from experience in dealing with patients), and...curiosity (i.e., creative stimulous).

The Book by Von Oech, "A Whack on the Side of the Head" would be mandatory reading for every allergy fellow.

It is my contention that truly creative allergists are in short supply...and that's because of blocks to creativity that every allergist subconsciously "employs" in his or her practice. And these blocks to creativity slow down advances in the allergy community. Advances that are within our reach if we think creatively. How can we have a Renaissance of creative thought in our Allergy Community?

By removing the Roadblocks to Creativity...

Allergy Creativity Roadblock #1: There is only one "right answer".

To quote Von Oech, "Nothing is more dangerous than an idea when it's the only one you have". Example: SCIT works for immunotherapy. Stop there. Don't ask the question--can we deliver immunotherapy more safely, effectively, than with SCIT? We have one idea. SCIT works. Nothing else does. And nothing else is even considered.

Allergy Creativity Roadblock #2: Logic can kill creativity.

As a former engineer, this rule absolutely kills me, but it's still a rule we have to follow for creativity. Simply put, there is a time and a place for logic--I use it minute-by-minute to solve clinical problems daily encountered in my practice--but there is a time and a place for creative thinking as well. What we need as allergists is a "time out" from logic so we can get as many ideas as we can, no matter how crazy--the crazier the better. For the Creative Allergist, it is the patient who "doesn't make sense" that is the patient we can learn the most from.  Last month, I mentioned the recent review by Bahna on food additive sensitivity, in which he concluded that there was not one report in the medical literature on desensitization to food additives (despite of course multiple reports on successful ASA desensitization). Well? Doesn't anyone have a crazy idea?

Allergy Creativity Roadblock #3: Break some Rules

As creative, Renaissance Allergists, we need to ask ourselves the tough question, "What 'unwritten' rules are currently in place in my profession that are stopping me from helping more patients productively?" Here are a few "unwritten rules" in our profession--1. To paraphrase Patrick Henry, "Give me IgE or give me Death", 2. Head, neck, lungs. The allergists domain. Nothing else. We all need to break a few rules, and see where our thinking leads us. The pathetic tragedy is most allergists can't think outside the box, because they don't even realize they are in one.

Allergy Creativity Roadblock #4: Being Creative is 'Not my Job'

The good allergist, we're taught, plays by the rules, and follows the lead of our professional societies--we rely on them to be creative. Nonsense. We can never rely on a professional society to be creative, when it has vested political, financial, and other outside interests which can atrophy any feeble attempts at creativity. As individual allergists, we have to realize that we are NOT fully doing "our job" UNTIL we approach our field in a creative fashion. Creativity starts with the individual allergist, not the professional allergy societies. Not the other way around.

Allergy Creativity Roadblock #5: Fear

I've saved what I feel is the most potent roadblock to allergy creativity to the end: Fear. Face it: It is hard to be creative when you are fearful. And if there is one disease that Allergists suffer from currently, it is a (possible terminal) case of fear:Fear of declining reimbursements from insurance carriers--especially if we use SLIT and not SCIT. Fear of increasing competition from ENT's, Family practitioners, etc for our patients. Fear of SLIT-based pracitioners and pharmaceutical companies making better and better treatments that "take away" the need for an allergy referral and put allergy management back into the hands of the primary practitioner. Fear of "internet educated" patients desiring help with delayed food sensitivities and other areas we aren't really interested in or know how to deal with. In truth, we are a fearful lot. And, as I've said, it's hard to be creative when you're fearful. But there's a cure:

There is no fear in love [dread does not exist], but full-grown (complete, perfect) love turns fear out of doors and expels every trace of terror! For fear brings with it the thought of punishment, and [so] he who is afraid has not reached the full maturity of love [is not yet grown into love's complete perfection]. —1 John 4:18

Simply put, if we love our profession, our patients, and our calling with enough passion, we'll approach creativity without fear.  And then advances in allergy can really be made.

Later, Dude

It is truly rare that I read a newspaper article that resonates with my opinions & beliefs like the article, "Where are Today's Leonardos?" by Dr. Howard Zucker  in USA Today.  Although the article was officially addressed to the graduating class of 2009, it could just as easily have been addressed to our professional allergy community.  In his article, Dr. Zucker (a resident fellow at the Institute of Politics at Harvard University), states

"Perhaps it is time for a rebirth, a time to create a better world through the energies of the Class  of 2009"...The Renaissance was a period when our search to perfect one's worldly knowledge transcended obstacles and bridged intellectual divides.  Students of creative thought--including da Vinci, Michelangelo, Copernicus and Galileo--questioned conventional wisdom...  Just as the Renaissance masters cast away conventional concepts, so too shall we discard friction that creates inertia in our thoughts."

Conventional Wisdom in the allergy community today involves several key underpinnings, which permeate all thinking and research in the field and (in my humble opinion) don't exactly "transcend obstacles and bridge intellectual divides".  Here are 3 key points in allergy Conventional Wisdom:  

1.  Since IgE mediated disease is the only "true" allergy, it is the only sensitivity we should be concerned about. Delayed food reactions, mold reactions, etc. really aren't our concern...so let's sweep them under the rug.  Let them die a death of benign neglect, not flourish in an atmosphere of curiosity...

2.  Asthma and upper respiratory disease should encompass what the allergist is "all about".  Other organ systems (besides pulmonary) should (once again) die a death of benign neglect as it regards interest in them as allergically responsive systems.  

3.  Other chronic disease states--chronic fatigue syndrome, fibromyalgia, migraine headaches, interstitial cystitis, have no allergic component, because everybody knows they don't.  So let's not be curious and study if indeed they DO have an allergy component to them.  

Examples of this "intellectual straightjacket" abound.  You can generally pick up any current issue of any allergy journal and see Conventional Wisdom at work--and trumpeted...Here's just one small example:  In the June issue of Current Opinion in Allergy and Clinical Immunology DRs. Randhawa and Bahna wrote a comprehensive review entitled "Hypersensitivy reactions to Food Additives".  They comprehensively review the protean manifestations of food additive reactions, and I heartily recommend the article for those allergists who see this problem in clinical practice.  However, near the end of their article, they state:

To our knowledge, there are no published reports on successful desensitization procedures.  

What?  You mean there isn't even a single case report in the entire body of medical literature on successful desensitization to food additives, despite multiple articles on successful aspirin desensitization?  Hello--isn't anyone anyone curious & interested?  Where's creative thought?  

It was this form of unconventional thinking that drove me to try oral desensitization to yellow dye #5 in a patient I had seen in my office earlier, who had presented with a history of seasonal allergic rhinitis, and repeated urticarial reactions to foods containing yellow dye.  As with many allergy patients, she wanted help with the "difficult issue" (dye sensitivity), and not the "easy issue" (allergic rhinitis).  As a businesswoman, she frequently went on trips and ate at restaurants, and found it always a risky procedure

We began her on a progressive program of yellow dye oral desensitization, starting with dilution #9 of yellow dye #5, and working progressively up to a dilution #1 without serious problems.  We knew we had successfully desensitized her when she told me she was on a business trip and gulped down a glass of Tang, which she had mistaken for Orange Juice, and had no reaction. Conventional Wisdom would have just treated her for her allergic rhinitis (which she could handle just fine with an OTC antihistamine, thank you).  

So here's the thought for the day--are we graduating Leonardo's from our allergy training programs, or just good Asthmalogists and technicians?

Do allergists think "outside the box"--or inside a straightjacket? 

Later, Dude

It was with bittersweet pleasure that I read the "JAMA Classics" article "Dr. William W. Duke:  Pioneer in Platelet Research" that was just published June 3, 2009.  Dr. Kickler, in his commentary on this classic article (first published in 1910 by Dr. Duke) states:

...when Duke published an article in JAMA on the role of platelets in hemostatis, probably few individuals realized that this report would be judged as one of the outstanding contributions to the science of medicine during the first half of the 20th century...this JAMA Classics article by Duke is historically important for 2 reasons:  it defined the role of platelets in hemostasis and it documented the therapeutic efficacy of blood transfusion in treating thrombocytopenia..."

There is always a danger in "cherry picking" a great physician's body of published work--you might give the erroneous impression that's ALL they really accomplished....  I pointed this out in my earlier commentary on a recent article on Dr. Warren Vaughn, another Renaissance Allergist, published in the JACI that didn't (in my humble opinion) adequately due justice to his contributions to the field of food allergy.  

In truth, I count 97 total publications by Dr. Duke over his lifetime.  Less than 10% of these actually deal with platelets.  Dr. Duke was fascinated by the wide range of symptoms that food sensitivity could cause, and abided by the maxim "one mucosal surface" instead of the mantra "one respiratory tract" (used by so many "allergists" today) to describe the wide range of manifestations that allergic disease could cause.  Here are some articles he also published:

Duke, WW:  Food Allergy as a cause of abdominal pain.  Arch Int Med.  Chicago 28:151, 1921.

Duke, WW:  Food Allergy as a cause of abdominal pain.  South M J Birmingham 15:599, 1922.  

Duke, WW:  Food Allergy as a cause of bladder pain.  Ann Clin Med 1:117, 1922.

Duke, WW:  Food allergy as a cause of irritable bladder.  J Urol, Baltimore 10:173, 1923. 

Duke, WW:  Meniere's syndrome caused by allergy.  JAMA 81:2179-1923.

Duke, WW:  Urticaria caused specifically by the action of physical agents (light, cold, heat, burns, mechanical irritation, and physical and mental exertion) JAMA 83:3, 1924.  

Duke, WW:  Mental and neurologic reactions of asthma patient.  J Lab & Clin Med 13:20, 1927.

Duke, WW:  Allergy as a cause of gastrointestinal disorders.  South M J 24:363, 1931.

Duke, WW:  Rapid and more accurate method of determining pollen count in air.  JAMA 99:1686, 1932.

Duke, WW:  Soybean as a possible important cause of allergy.  J Allergy 5:300, 1934.

Duke, WW:  Wheat miller's asthma.  J Allergy 6:568, 1935.

I stress this is only a fraction of the allergy articles published by Duke--it is by no means a complete list.  It is ironic that the commentator of the article on Duke and platelets (Dr. Thomas Kickler) did not at least reference JAMA's OWN TRIBUTE on Duke's life:

William Waddell Duke 1883-1946, JAMA 130:1185, 1946.  

Duke was obviously a brilliant allergist who made important contributions to the specificity of food allergy, in addition to making important contributions in the field of hematology.  How do I know about Duke?  One of my mentors (Dr. Theron Randolph) recalled seeing Dr. Duke at an allergy conference in 1933 in Atlantic City New Jersey, while he was a senior in Medical School.  He studied Duke's life, and published his bibliography.  I have a copy of that bibliography.  Dr. Randolph stated that  

"Duke's remarkable book published in 1925 really opened up the field of food allergy...Duke related specific foods and simple chemicals to a wide range of allergic symptoms, including headache and bewilderment resembling delirium..."

William H. Duke:  Pioneer in Platelet Research

                             AND...

                    Renaissance Allergist.

Something to think about.

Later, Dude

It was a beautiful day in May, a few years ago, when she first walked into my office.  She had an earnest look on her face...before I could introduce myself and welcome her to our clinic, she blurted out her urgent concern:

"Dr. Kroker, please help me with my Myasthenia gravis..."

Of course, as an allergist, my first thought was "you've come to the wrong place, lady", but I resisted the temptation to say what immediately was on my mind, and asked her to simply tell her story...

"I've had Myasthenia for about 4 years, confirmed at a large tertiary care center...I use Mestinon, primarily for ocular symptoms, but because of GI side effects, I try to minimize it whenever possible."

"I've also had allergy symptoms in the spring and in fall for many years.  I was allergy tested in the 1960's and was on injection immunotherapy for about 2 years when in Oklahoma.  That helped reduce the respiratory symptoms, but now I've been in the Midwest for about 4 years, and I've noticed that in the spring and fall, when my respiratory allergies flareup, my eyelids will droop, I'll get facial weakness, and need ALOT of mestinon. At other times, I'm relatively fine.  I take Flonase for my nasal congestion, and haven't been on injection immunotherapy for many years".

"I also have itchy skin, and use Allegra all the time.  I'm also prone to fluid retention, and use "Lasix".  

"Do you think you can help me?"

The desperate look in her eyes was accentuated by the drooping of her left eyelid...In truth, I have seen many cases of what I call "The Allergy Interface"--whereby an allergy condition aggravates a coexisting chronic disease.  We must never forget that when we read about any chronic illness in a medical textbook, website, or magazine article, there should be a caveat attached to the disease discription:  i.e., "this is the disease's presentation, natural history, and response to treatment, assuming that there are no other coexisting illnesses, and the patient is otherwise in fine health" (italics mine).  Believe me, I have seen allergic disease aggravate many other coexisting chronic diseases, including chronic fatigue, fibromyalgia, and even more "exotic" illnesses like Hereditary Cerebellar Ataxia (but that's another story for another time...).

We did intradermal testing, and found strong responses to molds, and (very interestingly), a 14mm wheal on dilution #2 of TCE and a 15mm wheal on dil #2 of Candida antigen.  

I found the strong immediate responses to molds--and especially Candida intriguing...she had been on multiple antibiotics and steroids in the past, and undoubtedly had significant commensal colonization of Candida.  

What was most interesting was that after skin testing her, her left eye drooped further, and became almost totally closed...

We began her on a program of SLIT for molds, and Candida, and a course of fluconazole for 14 days.  We subsequently found a RAST positive score for Candida of >100 ug/ml of antigen in her blood.  Also elevated antibody levels to wheat and egg.  We changed her diet, began SLIT, and had her keep a pill count for her Mestinon useage....

Over the next several years, she has had dramatic improvement in spring and fall respiratory symptoms, as well as her seasonal Myasthenia flares...She stated on her followup visits "my eyes are real good" and took an overseas trip without difficulty.  Her use of mestinon has been reduced by perhaps 75-80%. She doesn't want to discontinue SLIT under any circumstances...When I would see her in the clinic, her eyes were bright, not drooping, and...most importantly..she no longer had the desperate look in them that she had on her first visit with me.  

The Allergy Interface.  Something to think about.

Later, Dude 

Congratulations!  After two years of Fellowship Training, you're about to be done...and be certified as an Allergist.  The whole "World of Allergy" awaits you...and you're about to take the big step forward into directly caring for patients on your own...As someone who has been "in the trenches" for nearly 30 years in treating allergic diseases, I have a few words of advice.  This letter could be entitled many things, but perhaps the best title would be

"Mistakes I've made and Lesson's I've learned"

For you see, I've found that not everything you've learned in your training program applies to the Real World of allergy. Naming and learning leukotrienes is one thing, but dealing with patients is quite another...Here are some things to think about when you begin to see patients--lessons I've learned in the last 28 years that have helped me in my practice:

1. Lesson 1: In the Real World of Allergy, patients don't give a damn whether they're sick because it's "IgE-mediated allergy" or not--they just want to get well. You'll see many, many patients with adverse reactions to foods and molds where your prick test is negative, and telling the patient "they don't have an IgE mediated allergy" is very cold comfort to them. They want answers, and telling them what it ISN'T is not nearly as satisfying to the patient as telling them what it IS. A practical point--they're not likely to refer you a whole lot of future patients, either. Here's the clinical pearl: In the Real World of Allergy, you've got to get comfortable with non-IgE mediated reactions--and fast--if you want to be a superior allergist...

2. Lesson 2: You've got to get experienced in delivering immunotherapy regularly in your practice, and preferably in a well tolerated, safe and effective form: SLIT. If the only thing you're interested in is treating asthma and allergic rhinitis with only drugs, you'll be a very lonely--and poor--Allergist. Face it: we have alot of competition for treating the asthmatic patient, and the allergic rhinitis patient. We've got good symptomatic drugs too--which the family physician and pulmonologist and otolaryngologist can all deliver. You've got to deliver something the family physician and the pulmonologist and the otolaryngologist can't deliver--and that's immunotherapy. SLIT is the wave of the future. Bone up on it. Fast.

3. Lesson 3: There are other things in the Allergist's life besides asthma. Open up your vistas, and start thinking of ALL mucosal organs (and the skin) as targets for allergic disease. Our professional societies have done a good job at "marking our territory" as asthma--that's all well and good, but you'll see plenty of patients with urticaria, migraine headaches, fatigue, and other issues besides asthma. Many of these patients come with a mix of IgE and non-IgE mediated illness. In truth, the allergist who only treats asthma is like the musician who only plays one song: It gets pretty boring, and is an incredible waste of talent...

4. Lesson 4: Revel in the mystery of allergy--and develop your sense of curiosity in your practice. Just because we can't EXPLAIN a patient's reaction in terms of what we presently understand from our training program, there is no need to deny it exists or delight in the mystery of how it happens: Why does Mrs. Smith get tired shortly after eating wheat products? Why does Mr. Smith get a headache 12 hours after cleaning up a moldy basement? Why do Mr. and Mrs. Smith have negative prick tests and IgE negative RAST tests to wheat and mold? There is a subliminal tendency in many young allergists to not be interested in anything they can't explain. An observation is DENIED because the PATHOPHYSIOLOGY is unclear. That's backwards. It is the patient reactions we can't explain that should interest us the most! Thinking should begin with the NEGATIVE prick test and the NEGATIVE RAST test...not the positive ones. There are many, many, things we do not understand about how food and aeroallergens affect the patient, and the sooner we humbly acknowledge this, the better. This is the "Grand Mystery" of allergy. Accept it, embrace it--and study it...

Keep these four lessons in mind as you start your practice--you'll have a satisfying and rewarding practice for many years to come.

Later, Dude