Want a scary thought? How about this one: How do Allergists think?...now THAT's a scary thought...be scared...be very scared....Actually, this question came to me while I was reading Jerome Groopman's excellent new book, How Doctor's Think. Basically, Dr. Groopman tackles a taboo subject--misdiagnosis--by discussing how clinical errors are made by even the most experienced and clinically astute physicians. In truth, multiple studies confirm that very few clinical errors in diagnosis are made because of lack of proper data.  They are made by misjudgement.  And I can relate--although I've made a few brilliant diagnoses, I can also look back on prior cases where I misinterpreted clinical findings and came up with the wrong answer. The very idea of a misdiagnosis is hateful to me, but we all have to face the fact that no clinician, no matter how good he/she is, can bat 100% all of the time. And of course, I am always better at "seeing the speck in my brother's eye than the log in my own." And with that humble and sheepish admission, I have the following ruminations:

As a consulting allergist who sees patients for a second or third opinion, I often see situations where patients have already seen one, two, or even three allergists without satisfactory results. Some of these patients, of course, never had an allergy condition to begin with. However, more often than not, in my experience there was an underlying allergy-related condition that was missed. What gives? To a large extent, I believe as physicians, we "do what we're told" by Conventional Wisdom--i.e., our medical organizations, societies, and peers. And so it happens:

1. We do what we're told--and we're told that we should emphasize asthma control--with symptomatic medication adjustment. Finding the causes of the asthmatic problem seems to be a secondary issue for us...If anything, we do a perfunctory group of prick tests and they're negative, and we stop looking for triggers.

2. We do what we're told--we're told that food allergy is IgE mediated and if it isn't IgE mediated, it isn't a food allergy, and therefore we stop looking...non-IgE mediated food sensitivity triggers be damned.

3. We do what we're told--we limit immunotherapy to the elite 15% of patients, and we're told that SLIT is still experimental. So we cautiously use SCIT on a few patients, and treat the other 80% with medications. And we give "lip service" to investigating a new form of immunotherapy...and immunotherapy, after all, is the ONLY disease modifying agent we have...but we don't really care about that do we? 

4.  We do what we're told--we're told that IgE mediated food allergies can't "be treated", so we practice avoidance with our patients, hand them an epi-pen, and hope the child or adult doesn't die from an accidental exposure to the food in the meantime.   

5.  We do what we're told--our major allergy societies both have inserted the word "asthma" into their titles--as if this is the only thing we should treat. Proverbially, we've peed on the tree and declared that this is OUR territory...and by implication we really aren't THAT interested in seeing ANYTHING else in allergy--just wheeze and sneeze, if you please (pardon the rhyme). No urticaria, food intolerances puhleeeeeease. "Good morning, Mrs. Smith--how are your lungs today?" "Need a new inhaler?"

6. We do what we're told--because we're not curious enough--and creative enough--with our allergy patients. Period.

Let's get busy THINKING about our patients, being CURIOUS about such things as late phase cutaneous reactions, allergy in parts of our body OTHER than the respiratory tract, delayed-onset food sensitivities...and new ways to treat allergy conditions safely and effectively (could that possibly be SLIT?) in short, let's  not "do what we're told"--sometimes we need to creatively think for ourselves--and our patients--and then our field can progress from its current stagnant  "siege mentality" and really move forward.  Then we'll be proud to answer the question "How do Allergists Think?"

Later Dude