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

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.