It's happening already, and a major crisis is present:  A powerful American institution, whose leaders lack vision, has largely pursued a "business as usual economic  model".  They suffer increasing competition from their more visionary overseas counterparts,who are more  aggressively promoting alternative (hybrid) technology. Demand by U.S. consumers for the overseas products increases, perceived by the consumer as more safe, and efficient.  In addition, workers in the industry, who have generous benefits through their contracts, are reluctant for change.  In short, the American institution is in increasing danger as being perceived by consumers as "out of touch".  They don't want a "business as usual" business model.  They want--and indeed demand--innovation.  

Think I'm talking about the Big 3 Automotive industry?  Wrong.  Think again.

I'm talking about the "Allergy Industry." 

Bailout:  An ugly word for ugly times.  Yet, that's what Detroit Automakers want (and think they need).  And the American public doesn't like it.  One bit.  Thomas Friedman, in the New York Times, wrote a devastating commentary on this issue in "How to Fix a Flat"  In it he states the frustration of The Common Man on this matter:

How could these companies be so bad for so long?  Clearly the combination of a very un-innovative business culture, visionless management, and overly generous labor contracts explains a lot of it....We have to subsidize Detroit so that it will innovate?  What business were you people in other than innovation?" 

 

And what's with the flood of big truck commercials?  Personally, as I watch commercials for American vehicles, I ask--does everyone in the world really NEED a big honkin' truck that has 4 wheel drive and can climb 50 degrees up the side of a mountain while hauling the Titanic behind it with a steel chain?  Does my vehicle really need to survive a chain-suspended drop from a helicopter? Maybe a simple fuel-efficient Honda would do just fine.  Know what?--it does for me. I don't need a vehicle that can survive being tossed out of the lake by the Loch Ness Monster.  I need a vehicle to get me to work and back home again as efficiently and safely as possible. And I suspect most people do too.  

Which gets me to the Allergist and the Allergy Profession...

Sublingual immunotherapy (SLIT) has now proven a convenient, efficient way to deliver disease-modifying treatment to the allergy population.  At the recent ACAAI conference, there was no longer any questionas to whether SLIT is effective.  (And that's a first). Meanwhile our overseas European counterparts don't just talk about SLIT, they continue to use  SLIT effectively and produce prodigious research.  I've never really heard of SLIT described as a "hybrid" technology. but if we continue to use our "automotive industry analogy",  that's exactly what it is--a blending of a conventional form of treatment (antigen extracts initially designed for injection) and combining it with a new delivery system (sublingually).  And, like most automotive hybrid technology now-in-days, it will continue to evolve and become more and more efficient.  SLIT as it now exists, will give way eventually to "second generation" vaccines designed exclusively for the sublingual mucosa.  Case in point:  Razafindratsita et al in the JACI (vol 120, pp 278-285), in an article entitled "Improvement of sublingual immunotherapy efficacy with a mucoadhesive allergen formulation", concluded that 

Mucoadhesive formulations offer the opportunity to improve dramatically sublingual immunotherapy in human beings, most particularly by simplifying immunization schemes. 

I've stressed throughout this blog how the individual allergist needs to develop his/her sense of curiosityin order to be a superior allergy clinician.  On an individual basis, working allergists, like their unionized labor counterparts in the automotive industry,  have "generous benefits" in terms of reimbursement for allergy injection immunotherapy (SCIT).  They worry about losing these benefits if they start utilizing SLIT.  As one allergist said, "I make a good living with SCIT--why should I change?"  Since insurance contracts largely don't cover SLIT, the average allergist doesn't  want to "risk" changing over to SLIT, even though the literature shows it to be more economicaly efficient, convenient, and safe.  Insurance companies won't pay for it if it isn't a "usual and customary" procedure, and allergists don't want to do SLIT if they lose their lucrative insurance contracts.  A "Catch-22" of the first order...

However, the problem is compounded by our "institutional leaders".  Our institutional leaders in allergy need not only curiosity, but the capacity for creative innovation.  While our overseas counterparts were developing "hybrid technology", we continued to have our own "allergy factory" geared towards injection immunotherapy exclusively, effectively ignoring the obvious public interest in alternative forms of immunotherapy that have potential for increased convenience and safety.  As an organization, we should be falling all over ourselves in aggressively investigating SLIT.  Instead, our institutions have a defensive posture.  The glass is either half full or half empty.  And they see it as half empty.  Plenty of old, tired arguments abound regarding SLIT:  "the European literature doesn't apply to our American (polysensitized) patients", or "homeopathic doses are used", or "there is no consistenet recognized effective dose for SLIT", or "It's not FDA approved for use" (a blatant lie--it's off-label use of an FDA approved extract--perfectly legal) My response to all this nonsense by the allergy community?

So What?  Let's get a life.  Dickering with tired, old arguments is  getting us nowhere--fast.  Let's be thinking creatively.  Let's be innovative.  Let's pursue new "technology" aggressively--in a positive fashion.  In short:

Let's get to work. Let's get a vision.  

Because if we continue dickering amongst ourselves on technicalities, other groups will bypass us, and we'll simply be left with a less efficient, less convenient outmoded technology, utilized by a dwindling "customer base".  And then the real crisis begins...

Is the Allergy Industry headed to a bailout?  It's already there--we're not financially bankrupt, but we have a more serious bankruptcy issue--with creative innovation.  Someone needs to rescue us from ourselves. I'm afraid we have run out of new ideas, creativity, and innovation.  We're scared. Not innovative. In short, we're intellectually bankrupt--and that, my friends, is where the bailout is needed.  

Later, Dude

One of the great theological writers of our time was C.S. Lewis,--a true "Thinking Man's Theologian".  One of his greatest works was "The ScrewTape Letters", and it was largely because of this work (and others) that he eventually made the cover of Time Magazine.  The Screwtape Letters" is a Christian Satire, first published in book form in 1942. The story takes the form of a series of letters from a senior demon, Screwtape, to his nephew, a junior tempter named Wormwood, so as to advise him on methods of securing the damnation of an earthly man, known only as "the Patient.  It's a truly great work...and as I was reading it again, I couldn't help but think...

                   What if there was a Screwtape Letter...                               for Allergists?   

Well, read on...

                                                                                     My dear Wormwood,

I have been informed of a most dire circumstance in your patient--namely, that he wants to become an Allergist.  This is very worrisome, and bears extreme concern and attention--for Allergists have the capacity to help many people (30% of humankind, so I'm told), and offer relief from suffering in the human condition--something that obviously we want to perpetuate whenever possible and The Enemy weeps to see.  However, we must make the best of the situation, and there is no need to despair, provided you work hard on certain things. At best, we can render him a frustrated, ineffectual healer who misses the true Potential of what Allergy care and treatment is, and lives out his life in a dull, monotonous manner, helping as few people as possible.  How do we do this?  It's not hard:  

First, if you notice, infectious disease specialists never have forgotten that they have to deal with bacteria, viruses, all the time.  Their starting point is the organisms that affect humans.  They seem to have the nasty habit of dealing with all organ systems affected by viral and bacterial particles.  The Allergist has exactly the same relationship with the environment--except with allergens instead of bacteria.  Therefore, it is extremely important that you do everything possible to help your patient forget that allergens are the focus of his work, and that they can effect multiple organ systems, just like viruses and bacteria.  There is fortunately, much you can do in helping him along this pathway of amnesia.  For one thing, make him think of himself as a one-organ doctor.  "Asthma, not allergens", should be the mantra whispered in his ear whenever you get the chance.  Get him enamored with the various colored inhalers that humans so like to use.  Make him lose site of his focus.  Remember--loving asthma (as if "love" is a word that we even approve of down here!) is not enough--we prefer to have him passionately obsessed (there it is!  a much more favorable word!) with it.   This will help immensely in limiting his potential to help all people who suffer from allergy.  Because It's true that all mucous membranes (and the skin!) can have allergic manifestations--but don't let your budding allergist realize that!  And remember--one of our great Allies in this effort are the many medical societies now-in-days that seem to focus on asthma, to the exclusion of the "bigger picture".  Remember, we want him to see Allergy as Asthma, and Asthma as Allergy. Period.   It's that simple!  

Secondly, stifle his sense of curiosity whenever possible. The most dangerous characteristic an allergist can have is curiosity.  You can do this in several ways.  By all means, encourage him wherever possible to view lab tests and prick tests as Gods themselves.  He should "stop thinking and start pricking" whenver he sees a new patient. Believe me, this works!  If a patient has a curious story that doesn't "fit" with a few negative tests, encourage him to--and I repeat myself--stop thinking.  Another good phrase to whisper in his ear when he can't come up with an easy answer to a human's problems is, "you do not have IgE mediated allergy".  That will make him superficially satisfied, and the human can continue to suffer!  Get him solely--completely--interested in IgE mediated issues.  The discovery of IgE was the best thing--and the worst thing--to happen in allergy.  Let's concentrate on the "worst" part whenver possible.  It will pay rich dividends for us!  

Thirdly, whenver possible, your future Allergist should not be encouraged to use immunotherapy for his patients.  For it's the only disease-modifying therapy at his disposal, and it carries the grave risk of helping patients to the greatest degree.  How do we keep the allergist from dealing with allergens, and using immunotherapy?  It's not really that hard--especially with the number and amount of symptom relieving medications at his disposal.  Help him get disoriented--to think he is helping the most when he merely controls an allergic process symptomatically.  Human Allergists love the word control.  They talk about controlling asthma.  Controlling allergic disease, etc. etc. etc.  Get him to love the word control. But better yet--get him to be (and here's one of my favorfite words used once again!) obsessed with it.  Avoid the word "cause" wherever possible.  You will have magnificently and completely failed if he becomes a curious allergist trying to find a cause for his patients illness! He should not be thinking of "causes" for his patients ills--just control.  The irony is that when he is thinking he is "controlling" asthma with his fancy inhalers and monitoring peak flow charts, all the while the "allergic march" they talk about continues!  The irony is he really isn't "controlllng" anything at all!  

But now I have to mention one more item...of gravest consequence and concern.  There is currently a movement in Europe espousing a newer form of immunotherapy.  As I mentioned earlier, your young allergist should not even be thinking about immunotherapy.  But I'm afraid it's to no avail in this case...he'll hear about sublingual immmunotherapy (SLIT) no matter what--and be thinking about it.  A dangerous development, to be sure.  But I'm confident we can make the most of it, if we're careful.  First, remember what I told you earlier about curiosity--you must stifle it in this regard.  Keep him happy with his old ways.  Bring up the emotions of fear and uncertainty and confusion to nullify any temporary excitement he might have for this new business of treatment.  Above all, make him think in a defensive manner when it comes to change in his field.  Again, our great Allies in this area will be his professional societies, so encourage him to dutifully follow their dictums, rather than thinking for himself.  Rather than embracing newer forms of immunotherapy it, he should be fighting them!  Remember, it's dangerous for the Allergist to think about allergens.  He could help somebody.  

I'm confident if you follow my advice above, you'll get the desired result, and we'll have one more unhappy, frustrated allergist brought into the fold!  

Your affectionate uncle, 

ScrewTape

Hey there all you mouseketeers...it's time for the Second Annual Allergist Poster Contest...even though it's 8 months early.  Why, you ask?  Easy. 

Because I said so.  

The First Annual Allergist Poster Contest was such a success we just had to repeat it sooner than 12 months.  And besides, there was no clear winner in our first contest.   Too many readers thought all 3 posters were equally good.  So I've had the CRAP (Committee Regarding Allergy Posters) working hard on another entry.  Meanwhile, I've been busy trying to find out where all the American Papers on Sublingual Immunotherapy are...turns out they're harder to find than O.J.'s knife...

True, we've got one nice but lonely American nice study from--you guessed it--our ENT colleagues in Ear Nose & Throat by Saporta & McDaniel , and a host of international studies--but where are our American Studies sponsored and supported by our American allergy academia?    I mean, if you look at the literature for 2007 alone, you will find more non-American SLIT studies than you can shake a caduceus at--from Antony, France; Turin,Italy; Melbourne, Australia; Murcia, Spain; Vienna,Austria; Istanbul, Turkey; Turku, Finland; Madrid, Spain; Messina, Italy; Como, Italy; Bari, Italy; Hoersholm, Denmark etc. etc. etc. We American Allergists are so busy demonstrating proper inhaler technique to our asthma patients we forget to study what we do best--immunotherapy.  And we ignore a particular form of immunotherapy that just plain rocks:  SLIT...

Earth calling all American Allergists--come in, please.  

Houston, we have a problem... 

So this year, our poster is set to epitomize the American Allergists interest in researching Sublingual Immunotherapy for ourselves...after all, if American Allergists are not just paying "lip service" to our European colleagues when they say they agree they've shown efficacy and safety for SLIT, then there ought to be a TON of research churned out by the Ivory Tower Types on SLIT from American institutions, right?  I mean we should see articles every other issue or so in the major allergy journals from American allergists investigating various forms/regimens of SLIT. 

Well, Gladstone, they ain't there.  

So, here's where I slap on another "Black Box Warning" for you faint-of-hearts, before I formally announce the official finalists in the Second Annual Allergist Poster contest--a contest to epitomize and symbolize the American Allergists interest in SLIT.  Here goes:

OK, those of you brave but curious souls who have read and accept the Black Box Warning to the left, you can see the finalists listed below, and I have to tell you in advance they're doozies.  The Ultimate "loose cannon" of allergists--the Angry Allergist--chose these finalists himself, after recommendations from our committee.   Frankly, even I have trouble choosing between them.  But don't worry, you can't go wrong.  Any choice seems ok with me.  The CRAP will tally votes, and then we'll announce a winner if we have one in an upcoming Blog listing. So drop me an email and vote now!   Operators are standing by.     Later, Dude. 

 Finalists in the Second Annual Allergist Poster Contest:

     Entry 1:        Entry 2:        Entry 3: 

Let's begin this one with a parable about marketing...and then we'll come back to my topic, which is "marketing the allergist".  And this is a good time to discuss the topic of marketing, given the impending marketing campaign the ACAAI is going to launch.  Admittedly, I'm no marketing Guru, but over the years I haven't had problems "marketing my practice".  I use common sense.  You might call it common horse-sense.  And speaking of horses, I haven't had problems like Jake, the Horse Trader....

"You know, time was when people would come in her and buy 2 or 3 horses at a time" muttered Jake, as he scratched his 3 month old stubble on his face.  "Now, it seems we can't get ANYBODY to buy a horse.  Nobody wants my business".  Indeed.  The business inside of Jake's Northern Horse Trading Post was meager, to say the least. People just didn't seem to want horses anymore...

So Jake hired a fancy city-slicker named Duane, to do an "image makeover" and help him out.  Looking around at Jake's Northern Horse Trading Post, Duane said "You know, Jake, I think your lack of business is because of a deficit in public awareness and perception of what you can provide.  You know all about the problems you face--the competition for transportation, and other people providing substandard  horses, and peoples reliance on catching and taming their own horses, instead of going to see you".You need me to help the public find out exactly who you are.  And the valuable services in transportation you can provide. After all, 'Nobody does it better than Jake', the horse trading specialist."  

Jake agreed.  But there was a problem.  A big problem. 

It turned out that the problem wasn't a deficit in the public's awareness of what Jake could provide.  It was the public awareness of what Earl's Northern Transportation (a business across the street) COULD provide. 

Earl's Northern Transportation (ENT) didn't sell horses at all.  They sold horseless carriages...yep, the 'ol automobile.  That new unproven mode of transportation which wasn't shown to be as reliable as the horse.  After all, too many questions remained.  But Earl could see the possibilities...and he sold them.  And Jake didn't see the possibilities.  And he stuck with that old reliable...the horse. 

Years later, people would laugh in their jalopies as they drove over the old sign of "Jake's Northern Horse Trading Post" which had fallen from the once proud but now dilapidated building.  Old Jake?  He was still trying to sell horses.  

But nobody paid him much attention.  He was, in a word, simply "irrelevant". 

Well, I can almost hear you saying..."what's the point?"  It's rather simple:  As I see it, we can market ourselves as allergy specialists from two different perspectives:

1.  A marketing campaign based upon the "we're right and the public is wrong" philosophy--i.e., we allergy specialists have a valuable commodity that the public isn't "buying into" because of their lack of perception and education in what the allergy specialist can really offer.  In short, a "we're right and the public is wrong" philosophy to marketing. 

2.  A marketing campaign based upon the viewpoint that  the public ALREADY knows what we offer, and isn't BUYING IT.  

The only successful campaign will be item number 2. Period. 

You see, the public isn't dumb.  They hear stories.  You know, like Mabel at the Bridge Club being referred to an allergist for "assessment" by her primary care doctor.  She has a few prick tests.  Told she had no allergies.  She's given the same inhaler her primary care doctor gave her before (plus a big bill her primary care doctor DIDN'T give her before) and promptly dismissed.  But Mabel also goes to the Chiropracter for her bad back, who suggested she get off the milk she was drinking alot of for her bones.  "It might help your breathing" the Chiropracter says.  And you know what?  It does.  And Mabel's going to refer people to...guess who? 

The public hears other stories...about the use of sublingual immunotherapy (SLIT).  I recently read an article in a popular magazine, entitled "Having allergy problems, then try this..." and it went on to talk about SLIT.  And you know what?  Guess who they referred the readers to, in order to get SLIT?  I'll give you a hint--it wasn't the ACAAI, the AAAAI, or the AAOA.  And the public will then be referred to ....guess who? 

People don't give a damn that SLIT hasn't been  "validated" to the American Allergist's "satisfaction, despite the numerous positive European studies on SLIT.  They don't give a damn on how SLIT works.  All they care about is that they have a convenient, safe, effective way to take care of their allergies.  And you know what?  When they ask their allergist about it, they're told it isn't being provided because "the studies aren't in".  But  there are options.  Forward thinking allergists are beginning to use it...and the public will go to ....guess who? 

No, the problem isn't with the public.  The problem is with us. We're not marketing what the public wants.  And we better start marketing soon, or we'll end up like Old Jake's sign.  In the middle of the road, run over by newer, faster, more convenient immunotherapy options, and deemed simply "irrelevant".  A quaint reminder of times past... 

Later, Dude 

Well, it had to happen...the Angry Allergist has to weight in on one of the most important topics in medicine...the one item that's gotten even more hype than the iphone...yep, you guessed it...the electronic medical record--or, EMR.  This little baby's supposed to do everything...I wouldn't be surprised if it even offers a cure for global warming.  And everybody's behind it.  The government, medical associations--you name it.  It's a sacred cow that nobody wants to criticize.  ...which makes it a perfect topic for my blog, right??

Before I weight in on this subject, I want to inform you of a few things:  First, we've been using an EMR in our office for about a year now, so I've had experience in dealing/grappling/struggling with it.  We have a superb EMR in-house support staff that has (in my opinion) worked as hard as conceivably possible to produce the best quality EMR designed for us.   Finally, by nature (as a former engineer), I LOVE computers.  (The last laptop I bought was tricked out with a dual hard-drive RAID 0 configuration with an overclocked CPU).  Now, that being said, I'll weight in with a few thoughts.

Perhaps the old adage, "one picture is worth a thousand words" will suffice.  Check this one out:

Recognize it?  When Leonardo Da Vinci created his painting, he started with a blank canvas, and painted this masterpiece.  But if he was using an EMR to create his masterpiece, I think it would look something like this picture below:

Not quite the same, is it?  Well, that's what I seem to get with the EMR.  In truth, some of the "softness" of the medical record just seems to be missing with the EMR.  I can't explain it.  I just know it. 

Oh sure, there are what I euphemistically call "point and click" patients, where the history is concise, the problem focused, and all the boxes can be filled easily on the EMR.  But for the complex patient, the ones who can't be "precise" about dates/times/relationships, and relate their history in a digitally coherant fashion, then placing them in an EMR is a real challenge...

And therein lays the danger of the EMR.  The physician may become so focused on "fitting" the patient into the EMR that he/she loses focus on what their primary goal is--to listen to the patient, and figure out what the heck is going on with them.  For example, In a a recent article in the Annals of Family Medicine, it was found that EMR useage did not guarantee better diabetic care.  In fact, the researchers found that in offices that used electronic medical records actually offered poorer quality care compared with those doctors who didn't use them.  As a consulting specialist, during an initial patient interview, I am often faced with a plethora of records the new patient brings in with them for my review.  They bring in complex typewritten histories.  I have to assimilate this information, make relationships, and solve problems. Rapidly.  I need to shuffle papers, circle lab tests from outside sources, frequently refer back to several lab tests, etc.  My mind works fast.  It's on the move.  Documentation, point-and-click be damned.   

The EMR is an excellent repository of data.  And you CAN do neat things with digitized data.  But I am not (first and foremost) interested in depositing that data.  I am interested in using the data to solve specific problems.  The EMR is here to stay.  I'll still use it, but will (I suspect) like most physicians, learn to make peace with it.  I still start (like Leonardo) with a "blank canvas"--my visit notes.  And I scribble down what seems important.  I make relationships, write down a few thoughts.  And solve problems.  And then, as time permits, I "point and click" to enter the most important data into the EMR.  Later.  When the patient's gone.  I minimize EMR use with the patient in the exam room.  Eye-contact and personalization of the interview can insufferably worsen otherwise

In short, the EMR exists FOR the patient's benefit--and not the other way around.  I suspect--and worry--that our health care system sometimes reverses this order...and if it's put the other way around and it ends up becoming the focus of our attention--and not the patient--then it just morphs into another sort of "EMR"--the Extremely Mediocre Record...and let's hope this doesn't happen....

Later, Dude