I have said before that our field of Allergy is most similar in dimension to that of Infectious Disease. Simply put, the infectious disease doctor is interested in a wide array of pathogens that affect a variety of organ systems.  The allergist, in contrast, should be interested in a similarly wide array of allergens and how they affect a variety of organ systems.  We should accept (like our infectious disease brethren) than a pathogen or an allergen can attack a wide variety of organ systems simultaneously.  It is my contention however, the the infectious diseae specialist is a better diagnostician than the allergist in many cases.  Because in "real life" the allergist comes up short in  two critical areas.  

First, the "usual" allergist is just interested in how allergies affect  ONE organ system (the respiratory tract) and gives lip-service to other target organs.  We've even changed the name of our official societies to include the word "asthma".  Now how would it go over if The Infectious Diseases Society of America changed its name to "The Infectious Diseases and Pneumonia Society of America?"  (For example, how many allergists got excited and wrote Letters To the Editor on the recent article on "Atopic Irritable Bowel Syndrome" Published in The Annals of Allergy by Tobin et. al? Any lectures or talks on this topic at our recent annual allergy meetings??)

The second area we come up short in is our emphasis on CONTROL of symptoms, and our poor diagnostic skills in finding the CAUSE of symptoms.

Here's a scary thought:  What if the Infectious Disease Specialist behaved like the typical Allergist?  A quick scenario:

...the patient is in bed, hot and feverish, with a stiff neck and drifting in and out of coherancy.  The Infectious Disease specialist is called in...he examines the patient and makes the diagnosis of "Meningitis", and promptly tells the nurse of the Meningitis Action Treatment Control Plan.  Temperatures are bracketed into green, yellow, and red zones, and a peak temperature monitoring system (PTM) is used to chart the temperatures. The patient's relatives are taught to use the thermometer and record the peak temps.   Intense attention is paid to using cold packs and aspirin in escalating doses based on the PTM.  Even an algorithm is derived for optimal control. ("more fever?"--add a step two medication to the regimen, like tylenol, in addition to the basic aspirin) The action plan is written down by the nursing staff.   Everybody's happy.  

Except the patient.

Another specialist is called in.  He agrees with the diagnosis, but isn't satisfied it's the ultimate diagnosis.  He's not satisfied with only symptom controlling measures.  A spinal tap reveals meningococcus.  Now real treatment--based on the underlying cause--can be begun.  

I don't know how many patient's I've seen who come into the office "patched up" on Advair, Singular, topical nasal steroids, and who had been shipped off the the GI specialist for "irritable bowel syndrome" and then to the psychiatrist for "chronic fatigue"--when it's all connected to issues the allergist diagnostically is responsible for, and unfortunately missed.  Patients come into my office with a bevy of prior peak flow readings, asthma action plans, and yet...feel miserable and frustrated.   

...This issue is almost a philosophical one. There are "layers" of diagnoses, like Russian Dolls.   What we may think of at first as the "real" diagnosis may be, upon further investigation,  only a secondary issue behind a primary allergenic cause.   There are "layers" of diagnosis, aren't there?  Was the correct diagnosis in the parable above "Meningitis"?  Technically it was, but the causative agent is critical to treatment.  

Jerome Groopman in his book "How Doctors Think"  tells the poignant story of the man who came into the ER and had fallen--he was diagnosed as having a broken leg from the fall.  The leg was casted in the ER.  He went home.  He became progressively weaker, and was found to have fallen and broken his leg because of anemia.  The anemia eventually was found to have been because of colon cancer.  ...layers of diagnoses.

The Allergist should NEVER be content in labeling a disease and forgetting about looking for underlying triggers.  Diagnoses often come in layers, like Russian dolls.  A compassionate ear, an attentive manner, and an inquisitive mind in the allergist can often unravel all manner of puzzling problems.  Diagnostic excellent can never be fully attained, but should be constantly sought.  

Later, Dude