Maybe it's just because some of my relatives have recently had "less than optimal" interactions with their health practitioners, or maybe it's because of some recent patients I've seen who have also had "less than optimal" interactions with their former allergists, but I've gotten to thinking...about compassion...Now, I realize that thinking is a very dangerous activity for the Angry Allergist.  But what the hey...I live on the edge.  

Now, I realize some of you are 5 sentences ahead of me already..."man, now he's accusing allergists of not being compassionate to patients--this time the Shock Jock of Allergy has gone too far."  Well, before you degranulate all your mast cells...hear me out...but I warn you, the Shock Jock will nevertheless send a few volts your way...

You see, after 26 years, I've had alot of contact with patients.  And also alot of contact with allergists.  And in general we are compassionate to our patients...with one teensie eensie caveat--

You see, we  allergists are compassionate to patients---on our own terms. 

Conditional compassion.  

Compassion on our terms.   For the diseases we like to treat.

And we've got a bad case.  And this, in my opinion is the real crisis in allergy, not the crisis I spoke about in my earlier blog entry "why we don't need more allergists".   

What is conditional compassion?  It simply means when we see patients who "fit into the box" of our easily treatable diseases--asthma, rhinitis, we like them and have compassion for their plight.  We feel comfortable being around them, teaching them inhaler use, monitoring peak flows, etc.  And it seems more and more allergists are making little asthma clinics and becoming little "asthma doctors", catering mainly to the asthmatic patient, to the exclusion of other patients. Certainly our major allergy societies are codependents in this regard, with their incessant litany of "asthma-this and asthma-that".  So we want asthma patients.  Nothing else, if you please.  But what about the patient who walks in our office with a question on food intolerance? A history of delayed reactions to skin tests or injection immunotherapy?  A history of hyperactivity that seems definitely food related?  Chronic fatigue?   Headaches from foods?  Be honest.  How many of us want to really be compassionate and listen to a patient presenting with multiple complex food and chemical sensitivities?  How truly compassionate are we?  Judging from what I've noticed:

not very.  

Point-in-fact:  , we can't wait to get this type of  patient out of our office.  We find these patients distasteful.  A few perfunctory skin pricks,  a quick pat on the back telling them that they're "not allergic" and whoof!--out the door.  We just don't care. Don't believe me?  Then you're not living in the real world I live in.  I see it all the time as a consulting allergist. Compassion.  Conditional compassion. 

It wasn't always like this.  In the Golden Age of Allergy, allergists were interested in symptoms on all mucosal surfaces and involving multiple body organs--not just the lungs. Allergists really listened to their patients....And when Dr. Francis W. Peabody, on October 25, 1925, ended his lecture to Harvard Medical Students on "The Care of the Patient" he closed with the now classic dictum "the secret of the care of the patient is caring for the patient".  I don't recall he said anything about "caring for the patient with asthma exclusively".  Don't recall that at all.  (But then, again, I wasn't at that lecture in 1925 either...)      

But with conditional compassion the real tragedy is ours.  Not the patients.   Because when we don't care about the patient (except on our terms) , we don't really seek to find out what's really wrong with them if our perfunctory prick tests are negative.  But with compassion comes a sense of urgency--curiosity--in finding out what's really wrong with our patient.  And to seek--and find--what's really wrong with them--allergy or no allergy--, adds to our knowledge.  And with accumulated knowledge and experience comes wisdom. 

So the Spiritual Trinity of the Superior Allergist is compassion--knowledge--wisdom.  But the greatest of these is compassion...and we need more...unconditionally

Later, Dude  

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

Okay, I realize you when you read the title for this latest entry you're probably thinking:  "OK, now I'm sure this guy has completely lost it.  Up to this point, it was just a deep suspicion, but now I know he's one card short of a deck..."  All I can say, is "whoa there, Clarence, at least give me a chance!"  In my last journal entry, I pointed out that in Plato's writings one of the key distinctions between the tyrant "slave-doctor" who doesn't listen to his patients and prescribes treatments lickity-split, and the "free-man doctor" who cares for his patients much more thoroughly, is the detailed history that the latter "free-man" physician performs.  So let's talk a little about "the history". And let's talk a little about fishing. 

It's my own stubbornly held contention that there are alot of similarities between taking a good history and going fishing.  Please hear me out:  When I went up to Canada for my first fishing trip,  I was excited.  I read up on fishing, and spent hours pouring over books...I bought the best lures, rods & reels possible, and fitted myself out to the gills.  I mean I was LOADED when I went.  If there was a lure for walleye that existed, it was in my huge tackle box.  I had GPS BEFORE they had GPS.  I had fish sonar...I had every new gadget out there, and THEN some.  I naturally wanted a guide.  And I picked a good one....

His name was Frank, and he was an old Indian, perhaps slightly younger than the oldest Sequoia tree  in California, with a gnarled, weather beaten face to match. Another one of the things about Frank was that (to put it mildly) he wasn't fitted with "the latest gear".  He had a single old rod that looked like it had been hand-cut for him shortly before the Spanish-American war, and a beat up lure or two that looked like they had been hammered with an anvil and  almost bitten in half.  Frank didn't talk much in our boat, but what he lacked in words he made up for in results.  A typical conversation between us went something like this:

 Frank:  We fish over there (he would then point to the location)

 Me:  Why?

 Frank:  Because.

 Me:  How do you know there are fish there?

 Frank:  Because there are.

 Me:  But it looks like all the other places (I would then point out the similarities)

 Frank:  There are fish there. (he takes another drag on his cigarette at this point)

 Me:  Look, I've got sonar, why don't we give it a check?

 Frank:  No need.  Let's go

So off we'd go to another one of "Frank's spots".  The boat would stop, and we'd throw in our lines and the waiting would begin.  The conversation at this point would go something like this:

Me:  I'm not getting even a nibble.  You're spot isn't good, Frank.  We should have used the sonar.  

Frank:  Be patient.

Me:  But I'm not catching anything!

Frank:  Be patient.   

Me:  Whoa, you've got one Frank!  It's huge!  

And Frank out-fished me every time.  With his ancient rod.  I mean he would catch fish faster than he went through his cigarettes (and that was fast).  He out-fished me every time.  Even when I got pissed off at him and went out alone--by myself--(just to show him I could catch fish like him.) he still out-fished me.  

Now what does all this fishing "stuff" have to do with history-taking for the allergist?  There are similarities:  Let's look at how Frank was successful--

1.  He had experience.  Alot of experience.  He knew the lake--every weed-filled inlet of it

2.  He was patient--he knew the fish would bite at "his spots".  It just would take time.

3.  He didn't rely on the greatest hi-tech gear.  He relied on his experience an intuition. (curiosity) 

And so it is with history-taking...truly good history-taking  by a seasoned clinician "who knows the lake" approaches an art-form.  We hear that medicine is an "art and a science" and we see buildings festooned with such signs as "Medical Arts Building" but we allergists give "lip service" to the "art" part of "art and science" when it comes to medicine.  Truly good history-taking takes alot of experience. It's hard work.   And we have to be patient  when doing histories--detailed histories take time, and lots of it.  We also need to trust our mentors or "guides" to help us define and develop our history-taking skills as allergists.     And with taking alot of histories comes experience.  What does experience allow you to do?  Avoid mistakes.  How do you get experience?  By making mistakes.  And just like I couldn't learn the "art" of fishing by reading all the books I had, so you can't learn the "art" of history taking by going to medial school and reading books.  You have to "prowl the lake" under all sorts of "weather conditions" and get experience.  There's no subsitute.  Period. 

Why am I discussing this aspect of Plato's writings?  Because the history is--in my opinion--the single most important tool we have to work with in evaluating a new allergy patient.  Not the prick test.  Not the RAST test.  Not the basophil-histamine release test.  Not our Pulmonary Function test.  It is often with a good history by a seasoned "fisherman-clinician" that we can "catch the fish"--i.e., make the diagnosis.  We can be outfitted with the latest/greatest high-tech lab tools and EMRs, (like my fishing equipment) but they can't make up for good history-taking.  

And what is the true power of history-taking?  Because when you do enough histories, over 20 or 30 years, you begin to see PATTERNS in histories.  And recognizing PATTERNS as we take our patient histories is an enormously powerful tool.  And the next series of entries will discuss patterns I have noted as I have taken allergy histories for nearly three decades.  Patterns that help you see "the big picture" and have a thorough idea of what's going on with the patient, even before doing allergy testing.  Patterns that allow us, like Frank, to cryptically point to a given spot on the lake, and say, "fish here". 

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.