I think it's about time to take a break from all of the flow-charts and diagrams I've been showing you over the last 2 weeks, and relate a parable--one that has to do with why I'm writing about Diagnostic Synthesis in the first place...but before I do so, I've got to (are you ready?) do another black box warning to weed out the faint-hearted..."oh nooooooooooooooo" you say.  But take heart.  This isn't just "any" black box warning, this is actually a BLUE box warning...and if you read the parable below, you'll understand why I changed colors on you...

The  Allergist & the Preschool:  A Parable

Once upon a time there was an allergist.  He was busy in his practice, treating asthma.  Truth be told, he was basically an asthma doctor.  But he was bored.  After all, you can only give out so many inhalers and monitor so many breathing tests before it gets a bit monotonous.  He looked around for other opportunities.  Surely it wasn't with his patients--a lot of them had stomach issues, fatigue, cognitive dysfunction, migraines, etc. but he really wasn't properly trained to DEAL with any of that.  Only wheezes, and sneezes, if you please.  So he sat in his office, and handed out the latest inhaler du jour while the time on the wall clock slowly crawled by.  So he was DELIGHTED one day when his wife (who ran a preschool) unexpectedly called--it turns out she had come down with a bad respiratory infection from one of the kids and she offered him the "job" of taking care of her preschoolers for one day.   He excitedly cancelled all of his patients for the next day, and went to the preschool. Boredom relieved! 

As he looked around at the wide-eyed faces of the young children, he asked them what they would like to do.  "Let's play with blocks!"  said one child.  "Yes!  I LOVE to play with blocks!" said another.  "Could you help us build something pretty?" asked another.  So the allergist got out all of the wood blocks from a box near the door.  They were all different colors.  Some were red, some were green, some were white, and some were....blue.  

Blue was his favorite color.  Always was.  Always will be.  I mean he really loved the color.  And the blue blocks?  He loved them too--every last sliver of them.   Was hypnotized by them.  Down to all 8 corners and all 6 faces of every blue block.  He knew he just wanted the kids to play with the blue blocks.  And only the blue blocks.  They were the prettiest.  They were the BEST.  And he know he would like to play with just the blue blocks too.  He was determined to learn everything about the blue blocks he could.  How they stacked on one another, how they fit together.  How he could use them to build interesting things.  And how the children would be so impressed with the  all-blue structures he'd create. 

There was only one small problem: 

There weren't enough blue blocks to go around. 

And there was one "not-so-small" problem:

The kids wanted to play with ALL the blocks; not just the blue ones.

As he handed out the blue blocks, he began hearing the protests.  "Why can't we play with ALL the blocks?" one child said.  "With more blocks we can build bigger and more beautiful things!" 

"Because I want you to play ONLY with the blue blocks" he said,  "What's the matter--don't you like blue blocks?" 

When children complained they also wanted to play with the red or the green or the orange blocks, he told them "that's not what we're playing with here".  (He almost allowed one child to use purple blocks--close enough to blue to be fairly attractive--but at the last moment said no.  He didn't want to set a precedent.)  And so they began playing.  The children were understandably disappointed when they couldn't build much.  After all, the blue blocks were merely ONE PART of the play set.  And there weren't that many blue blocks.    

The allergist was unperturbed.  "We will continue playing  with the blue blocks for now", he said.  "if you have any questions on how to build things with the blue blocks I'd be happy to help out." 

Meanwhile, while the children played, he spent his time minutely studying every last woodgrain pattern in each and every blue block they had, and explaining to each child the different grain patterns in each blue block.  The children weren't that interested in all the minutiae of the blue block composition--they were just frustrated they couldn't use all of the other brightly colored blocks.  The only one having some enjoyment in this was...the allergist.  But after a while even HE had to admit (to himself only) that he really couldn't build THAT much with just blue blocks.  In fact, he became...bored...just like at his office practice. 

...The next day the Allergist's wife returned to the preschool... She asked her children how they liked her husband, the "substitute teacher" allergist. 

"He was boring" said one child. 

"He didn't listen to us" said another child. 

"He didn't help us build anything pretty" said still another child, "It was really sad.  I think he could have really built pretty things if he was just CURIOUS about how all the blocks would fit together".    

"I don't understand all those big words you're using", said another child, "but I can tell you what I know-- he was just a blockhead". 

...And so he was.

Later, dude. 
 

You know, Plato rocks.  A wonderful colleague of mine, (Dr. K.W.) a family physician in Minnesota, sent me some excerpts worth quoting:

And did you ever observe that there are two classes of patients in states, slaves and freemen; and the slave doctors run about and cure the slaves, or wait for them in the dispensaries--practitioners of this sort never talk to their patients individually, or let them talk about their own individual complaints?  The slave-doctor prescribes what mere experience suggests, as if he had exact knowledge; and when he has given his orders, like a tyrant, he rushes off with equal assurance to some other servant who is ill; and so he relieves the master of the house of the care of his invalid slaves.  But the other doctor, who is a freeman, attends and practises upon freemen; and he carries his enquiries far back, and goes into the nature of the disorder; he enters into discourse with the patient and with his friends, and is at once getting information from the sick man, and also instructing him as far as he is able, and he will not prescribe for him until he has first convinced him; at last, when he has brought the patient more and more under his persuasive influences and set him on the road to health, he attempts to effect a cure.  Now which is the better way of proceeding in a physician and in a trainer?  

                                                     Plato

                                                    The Laws
 

 Plato, in one fell swoop, has described what is so wrong with 20th century medicine in general, and with the practice of allergy in particular.  Certainly, in acute care medicine, especially involving trauma, the "slave-doctor" relationship may apply.  I see nothing wrong with the "tyrant" doctor dispensing life-saving measures (CPR, ventilator support, IV fluid support are examples) with a minimum of history (and cooperation) from the patient.  The problem with medicine now, and one major reason we are in the health-care crisis we are in, is that this paradigm does not work for chronic illness, which ultimately drains the bulk of our nation's healthcare resources.  Have fibromyalgia?  Take a  pill.  Have irritable bowel syndrome?  Take a pill.  Have migraines?  Take a pill. Have asthma--take an inhaler.   In short:  acute care "slave-doctor" medicine for chronic health problems just doesn't work.  Plato's latter "freeman" paradigm much more apply applies. We need to take thorough histories, and find the causes behind the patients chronic maladies--and this includes asthma as well as other allergic diseases. If we can find that chocolate triggers a patient's migraines, and the patient has less migraines, and needs less imitrex and the health care system is less burdened, what's wrong with that?  The same idea, of course applies to asthma--but I think we get too lazy and give up to easily.  We just aren't curious enough about our patients. 

Look at what Plato says about the "freeman doctor" who "attends and practices upon freemen"  He does the following:

1. "Enters into discourse with the patient AND his friends"
2. "he carries his enquiries far back, and goes into the nature of the disorder...at once getting information from the sick man"
3. "instructs him as far as he is able"
4. "will not prescribe for him until he has first convinced him"
5. "tries to set him on the road to health and effect a cure"

Let's take our management of asthma, for example.   Acute care of the patient with status asthmaticus is occasionally necessary, and lifesaving.   Orders are given by the doctor, meds are given, and (usually) the patient survives.  Fortunately these episodes are rare.  The slave-doctor paradigm shines in this setting, and frankly it's ok here.  However, someone has to ask the bigger questions:  Why did the status asthmaticus episode happen in the first place?  Why is the patient so unstable with his/her asthma?   Questions like these are very important because In truth, none of the medications that the status asthmaticus patient took for his severe attack are ultimately disease-modifying. 

Today, the allergist is so caught up with the mantra of "asthma control" that I seriously believe we have overshot the mark.  We're so busy with the "slave-doctor"  approach which goes something like this: "takethisinhalersomanytimesperdayandmonitoryourpeakflowsomanytimesperdayandmakesureyou'reinthe greenzoneandgototheERifyouentertheredzoneandshutupanddon'taskanyquestions." approach.  True, I'll give you that peak flow monitoring is a good thing, but why not equally fervently--and I mean fervently continue to hunt vigorously, relentlessly, and with  a sense of curiosity as to what's BEHIND each patient's asthma?  I think we allergists have the attention span of a lightning bolt when it comes to sitting down with the patient and really determining what's going on...In practice, usually what happens in most allergy offices is after a  few perfunctory prick tests and IgE mediated disease is ruled out, we feel we're done.  We've given up.  It's a chronic disease. That's that. Then we become like the man at the starting line at the Grand Prix (paraphrase):  "Gentlemen, start your inhalers".  And off to the races we go...

Let me give you an example of a true story about an asthmatic that doesn't stress medication-based "asthma control".  Pt. X comes to my office with unstable asthma.  Into the ER twice the previous month.  Her prior allergist (who also uses SLIT) had her on SLIT but she had poor tolerance--an unusual occurrence.  He was "controlling" her asthma as best he could with medication adjustments.  I have no quarrel with that, but he just wasn't curious enough.  She couldn't push mold treatment beyond even small doses.  The allergist thought she had mold issues from multiple molds, including Alternaria so the patient stopped gardening, closed up her home and turned on the a/c.  (good move).  Unfortunately, she wound up in the ER again.  Things got even worse.  So what was done?  More attempts at "asthma control" with more steroids and inhaler use, and less immunotherapy (because she wasn't tolerating it).  Now:  what to do?

Well, I got curious.

Now at this point I could have talked to her about "asthma control" and pushed more medications like her other allergist, talked to her about proper inhaler usage, demonstrated it, talked about peak flow monitoring and educate her on the side effects of her drugs, etc. etc. etc.  Instead, because I was curious, I skipped all of this mishmash and I used the rest of my time with her investigating why she had two intriguing phenomenon going on:

1.  lack of tolerance to SLIT for molds

2.  worsening of her symptoms with minimizing outdoor mold exposures--no more gardening, and having the air conditioning on in her home and the home closed up.

There were several possibilities for her worsening, of course--she could have run out of her medications, started a new med and had a drug reaction, had a diet change with a new occult food allergen exposure, a work-related occupational exposure, hidden GERD aggravating her asthma, or other intrinsic pulmonary disease mimicking asthma,  etc. etc. etc. After a review of her situation, I felt it was very likely (but couldn't prove on her initial visit) that she had major indoor hidden mold issues in her home and subsequent professional evaluation confirmed serious problems in multiple areas of her home, including her walls and basement with occult indoor mold exposure.  Temporary removal from her home, followed by extensive renovations has resulted in dramatic benefit.  By closing up her home, she effectively went "from the frying pan into the fire".  It also helped explain the perennial nature of her asthma, which was worse even in the winter, despite a lack of dust mite sensitivity.  With mold removal her asthma control is hugely improved.  Inhaler use has plummeted, and she has tolerated a buildup of SLIT quite well.  (That's a pearl:  if you have a patient with trouble building up on immunotherapy, one frequent cause is a total allergy overload--often in the home environment or in the dietary area.) But here's the biggest pearl of all:

Asthma control "takes care of itself" if the cause of the problem can be found, and if disease-modifying immunotherapy can be effectively given. 

Hey, I've got a full head of steam going now, so how about one final example:  Patient XX is admitted to the hospital after a severe exacerbation of asthma.  "Slave-doctor" treatment stabilized the patient, but the internist couldn't taper steroids in the hospital and the patient remained ill.  CXR clear.  On reviewing the chart, I noted a 12% eosinophil count.  Now that was interesting.  So I got curious.  On talking to the patient, he had noted the rather sudden exacerbation of his asthma coinciding with the onset of taking a H2 blocker for GERD.  We stopped the H2 blocker, ran serial PFT's and serial eos counts, and the eos plummeted to normal, the FEV1 went the right way, and excellent asthma control was reestablished as prednisone was discontinued. 

As my mentor in my allergy fellowship taught me--"we're specialists--we SHOULD see the tough cases and figure them out".  Just working on asthma "control" isn't good enough.  Doesn't cut it.  As allergists we need to find causes, and then remove what causes we can, and treat if at all possible with disease-modifying immunotherapy.  No excuses.  Like Nike says:  Just do it.

Later, dude.

Ever have a really good idea--I mean an idea that actually gets better the longer you think about it?  If you're like me, ideas like that are few and far between.  For me, they usually occur in the one spot I'm never bothered, and never harried--the shower.  The last really good idea (like those rare, really GREAT ideas I mentioned before) was "I'll think I'll go fishing in Canada."  Now that turned out to be a really good idea.  Anyways, (and I'm getting to my point) I happened to have another really good idea recently.  It all started while I was showering, and thinking about how accustomed (we) allergists are   to receiving brochures on numerous allergy-sponsored activities, including asthma camps, asthma support groups, and of course asthma poster contests.  These are usually met with much fanfare, as is everything having to do with asthma.  Poster contests for various diseases abound.  The AAAAI, for example, has sponsored a national asthma poster contest.  And then it occured to to me: what about the poor allergist...is he/she to be denied a poster?  Then one of these REALLY good ideas hit me like a lightning bolt:

What if we had a poster contest just for the ALLERGIST? 

How about a contest for a poster that epitomizes the American allergist and his current "state of the art" philosophy on the diagnosis and treatment of allergic disease.... Something that would truly symbolize the typical allergist's interest in allergy as it affects the entire body, his curiousity and open-mindedness for non-IgE mediated sensitivities, and his curiosity and openmindedness for new therapeutic options like SLIT, etc. etc. etc....Why couldn't allergists design their own poster--after all as our official socities have proclaimed in a common platitude--"nobody does it better than the allergist?" Right? 

In pondering such a poster,  some thoughts immediately came to mind.  But before I go further, I must mention that what I tell you is possibly offensive, and therefore this particular journal entry comes with a black box warning. 

Yep, you heard me right Sydney, a black box warning.  And you know what?  I'm surprised somebody hasn't already thought of black box warnings for blog entries.  I personally think its a killer idea.  You know, it seems these warnings are becoming more and more common on meds, and therefore why not on medical blogs?  It's merely a safety issue, to protect you, my dear readers, from unanticipated--and possibly hazardous--side effects.  After all, If it's good enough for protopic & elidel, (and Ketek) then its good enough for  the Angry Allergist Blogs.  So expect to see more of these as time goes by on my blog.  So here it is below--please read it and ponder before going any further, and remember this is offered as just one more service by the angry allergist.  (An aside to bloggers--feel free to cut and paste this warning for your own journal entries if you want! I'm waiving copywrite on this! )

So if you read this black box warning and want to skip this entry, just click out now on this link , and I won't be offended in the least.  Otherwise, knowing the risks, you may read on below:

 First Annual Allergist Poster Contest

The following are the 3 finalists in our choices for Winner of the First Annual Allergist Poster Contest.  Please feel free to vote for your favorite by emailing me.  We'll be counting them soon, and the first poster to get 100,000 votes wins...!

       ENTRY #1                       Entry #2                     Entry #3 

I know, it's soooo hard to make a choice...but give it a try.  Personally, I am leaning towards entry #1, but I realize you may have a different preference.  But no matter.  The best thing about it is (you guessed it) no matter WHICH ONE you choose... (dare I say it?) you can't go wrong!  So stay tuned!  Find out who wins...and see which new blog entries merit black box warnings!  What more could you want? 

more prevalent in the last 20-40  years.  To quote one telling statistic:  there were 6.8 million Americans affected by asthma in 1980, 13.7 million in 1994 and 22 million In 2005.  In addition, it has been estimated that the number of full-time allergists will decline by 6.8% between 2006 and 2020.  The solution proposed in the ACAAI white paper is to produce 120 more board-certified allergists annually.  In my opinion, this is a superficial solution to a much deeper problem in the allergy profession. One that we helped create and foster.  And without addressing the deeper problem, the proposed solution is a merely superficial one. 

Speaking as a professional allergists myself, I think we are both the problem (and the potential solution) to this crisis.  How could we be the problem?  Well, for starters, two major items come to mind:

    1. We have placed over-reliance and emphasis on pharmacologic symptom control of our patients problems, instead of immunological control based on an aggressive immunotherapy approach to our patients:  As a consulting allergist, time and again I see patients on nasal sprays, steroid inhalers, leukotriene blocking agents...and NO immunotherapy.  What gives?  We have become a specialty of "inhaler jockeys"...Inhalers and meds keep being blilthely "layered on" to the patient as the "allergic march" continues throughout their body.  Asthma "control"--not asthma "cause"--is paraded as a mantra...Reviewing outside records from other allergy clinics, I frequently find positive prick results, but no immunotherapy given.  Immunotherapy is reserved for the "elite few" and certainly is a small fraction of all patients seen in many allergy clinics.  

    2.  Failure to "market" ourselves effectively to primary care physicians and other specialists.  Perception is everything, and we've failed in this regard.  I recently made a trip to see my own family physician...during the course of my checkup, the topic of asthma came up, and he casually mentioned that "this is a disease for the family physician to treat..."  Why did he say that, in view of the fact that in his own clinic he has an allergist on staff?  Maybe because he sees he himself and the allergist as doing the same thing--you know, inhaler treatment, peak flow monitoring, etc.?  A pulmonologist from Minneapoplis came down to visit our offices, and I asked him what his opinion was of allergists in his locale, and whether he considered they were an asset to his practice.  "No", he said, "I don't use them...I found they practice 1970's medicine--do a few prick tests, and even when they are positive they don't do anything about them.  And they want the easy asthmatics too...when they get in trouble I have to handle the fallout". Let's face it, at least in my own regional area despite the crisis in allergy, allergists are not "bursting at the seams" in their practices with patients--which they should be, if the allergy crisis is indeed a real one.  For example, as a test, our own allergy nurse called a local allergist here in town to see how soon she could be booked to be seen as a new patient..."How about 1:00 today?" was the answer. 

In this weeks' ACAAI newsletter, Jay Portnoy said that testing and treatment of allergies basically defines who the allergist is.  And when it comes to the current state of allergy treatment, I''m reminded of the opening lines of Dante's Inferno:

 "Midway upon the journey of our life/I found myself lost in a dark wood"

The allergist has lost his way...and making more lost allergists is not, in my opinion, the answer.  The answer, in my opinion, is in finding the way. And why the asterisk in my heading?  That's easy.  Because when we find our way, we do indeed need more allergists...
 

One of the greatest dangers facing the practicing allergist today is simply becoming "irrelevant" to the public at large when it comes to seeking allergy care.  We face competition from many specialties.  Let me site an example:

"Patient John Doe sees me in my office.  He has come in for a "second opinion" on whether or not he has "allergies."  He's confused.  He wants reassurance he's on the "right track" with his health.  He has had 4 years of sinus problems.  He saw an ENT, and was reassured that he had no structural abnormalities contributing to his problems.  He was told to see an allergist.  He was given a few perfunctory prick tests, told they were "negative" and he had no allergies.  "So what's causing my sinus problems?" he asks.  The allergist shrugs, and hands him a steroid nasal spray and says "something about nonallergic rhinitis".  He doesn't like the explanation, and he only gets partial relief of his symptoms.   He continues to "shop around", sees a chiropractor who does kinesiology, he is told to stop using all dairy products, and his sinus problems go away.  He stops the nasal spray.  He's better.  Guess who John Doe is going to refer patients to in the future?  The allergist?  Or the chiropractor?

 By limiting our diagnostic testing and treatment options, many patients simply don't get the relief they want from the "routine" allergy referral. Patients see little difference in what the allergist offers, and what their family physician offers.  Many patients enthusiastically self-refer family members to alternative care practitioners, chiropracters, etc. but I have NEVER seen such enthusiasm for the traditional allergist.  Is our focus to narrow?  Do we overlook and not emphasize areas of IMPORTANCE to the PUBLIC--like food sensitivity/intolerance?  yeast allergy?  food additive intolerance?  mold allergy? 

These matters might matter little to the academic, on-tenure allergist, but they matter greatly to the community allergist.  For therein lays our livelihood--and our oath:  to help our patients.