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...
 

What?  ANOTHER history lesson?  First King Canute, then St. Benedict...now THIS?  More pictures of people long dead?  Oh noooooooooo you say...well I happen to LIKE history.   And those who don't understand history's lessons are prone to repeat them.  So suck it up. But I've got good news for you.  Actually great news. News that will probably keep you reading farther than you thought you would in this journal entry.  For as it happens,

This wasn't my idea at all.  

One of my many blessings is having creative colleagues at our clinic and one of them, Mary Morris provided me with the ideas behind the little story that I'll be tell you.   The comments, on the story are my own, however...so Mary doesn't have to worry...And the reason I'm telling this story is to give us some insight into the current controversey concerning traditional subcutaneous injection immunotherapy (SCIT) and the "new" more radical alternative--sublingual immunotherapy (SLIT).  In short, what can history tell us about happens when competing technologies "collide"?  In the early 1900's the frenchman Louis Daguerre (building on earlier work by (Johann Heinrich Schultz)refined a process  of making an exact image of a scene by exposing silver coated copper plates to iodine, making silver iodide.  He exposed the plates to light for several minutes, followed by coating the plate with mercury vapor heated to 75 degrees celsius to bind the image to mercury, and then fixed the image in salt.  The "Daguerreotype" produced an exact image of the scene--and photography was born. 

But that's not most interesting part of the story.  The really interesting part of the story is what the reaction was by experts in a competing field (painting)--as opposed to the public masses.  Across Europe, the new technology of the Daguerreotype was greeted with excitement and awe by the general public.  Exhibitions of this new technology of "painting in light" were held in the storied cities of Europe.  However, Paul Delaroche, one of the most respected French painters of the nineteenth century, solemnly reported on August 19, 1839--"After today, painting is dead."   On the other hand, at the 1860 Paris Exhibition, Charles Baudelaire denounced photography as "the refuge of failed painters with too little talent. It is obvious that this industry has become art's most mortal enemy.  If photography is allowed to supplement art in some of its functions, it will soon have supplanted or corrupted it altogether, thanks to the stupidity of the multitude which is its natural ally."

And what might this story tell us about our current controversey between SLIT and SCIT?   I believe there are three ideas to be taken away from this story:

1.  There may be room for two competing technologies--SLIT AND SCIT.  We all know that painting has "survived" photography.  In fact, far from destroying  painting, photography has actually been a major factor in its evolution. Just as photography is not the "mortal enemy" of paiinting, so SLIT shouldn't be seen as the mortal enemy of SCIT.  Similarly, I believe that SLIT and SCIT can coexist.  In fact, I currently have patients receiving SCIT from University-based allergists for their pollens, and who receive SLIT from me for their food and mold allergies.  Photography does not replace painting.  SLIT may not replace SCIT. 

2.  When it comes to a new technique, the "experts" can't always be trusted to have an accurate perspective on events.  We did not see the "death" of painting with the advent of photography.   Photography is not the "mortal enemy" of painting.  Yet many allergists, I suspect, are mortally "fearful" of SLIT.  And the American allergy community is about as enthusiastic for SLIT as european painters were enthusiastic for the advent of photography.  The masses of people, however, WERE enthusiastic about photography, and so it is with SLIT.  

3.  Although one technique may not supplant another, one technique may dominate another over time.  I have to admit it.  I like to take pictures.  I don't do a whole lot of painting.  In fact, none.  Most of my friends are the same way.  And when I read the newspaper or read magazines, photographs of course dominate.  Let's face it--photographs are just too convenient, accurate, and easy to take--and produce a darn good likeness.  They get the job done.  And SLIT, I feel, is the same way.  It's convenient, easy to take, and gets the job done. 

   So the allergist has to ask himself,  which will he/she be--the photographer or the painter?   Will he put down his needle and pick up a drop bottle?  Put down his brush and pick up the camera?  Or will he use both?  The choice is ours. 

So sublingual immunotherapy (SLIT) will be officially approved for treatment of allergic disease in the near future.  Then what?  Allergists will begin to do it, and like any "new" treatment, problems will probably ensue.  I put quotations around the word "new" treatment, since some of us have been utilizing the treatment for a relatively long time.  In my own case, I have been using SLIT for 26 years, and over the years have refined my techniques, with the aid of my colleagues in our clinic and keeping up to date with the European allergy literature.  And the SLIT literature largely DOESN'T comment on multi-antigen therapy, mold treatment, food treatment, latex treatment, etc.   I sure don't have ALL the answers for using SLIT most effectively, but I've had ALOT of experience in using it in a clinical allergy practice--and that counts for something.  With that prologue, let's get "down and dirty" and talk about things that the allergy literature DOESN'T address with SLIT.  And my clinical experience.

1.  SLIT with multiple antigens works.  To my knowledge, there is only one recent article addressing SLIT in multiply-sensitized individuals.  More will be done in the future.  I've used SLIT for multiply-sensitized individuals without problems for years. 

2. Hi-dose preseasonal treatment for mold (Alternaria) works, but clinically the incidence of side-effects is higher than with pollen.  

3.  SLIT works exceedingly well for late-phase delayed reactions to antigens.  You know all about these patients.  They are the ones who have a delayed reaction 6-12 hours or even 24 hours after testing in your office.  We then do intradermal dilutional titration (IDT) on them, and find the strongest dilution that causes NO delayed reaction, and begin SLIT on that dose.  This advantage alone would make SLIT worth it.  These patients often have chronic sinus problems, and are often negative on immediate testing, and treating the delayed allergies works.  Like dynamite. 

4.  SLIT works for latex allergy and foods. I treated my first allergic patient for latex several years ago--she was a dental assistant who was seriously ill at work.  She quit her job, but remained highly sensitive to even trace amounts of latex exposure.  SLIT has allowed her to tolerate casual contact with latex with impunity. SLIT also works well for food sensitivity, even for foods that patients are highly allergic to. 

5.  SLIT can have side effects in unstable and/or multiiply-sensitized patients.    Don't get lulled into thinking that ANY dose of SLIT in ANY patient can be given with impunity.  No so.  In one of my asthmatics for example,who was  co-sensitized to alternaria, dust and grass pollen, she would enter the ER every June.  Hi-dose preseasonal treatment with grass caused a drop in peak flow (monitored at home while on therapy) and symptomatic shortness of breath.  The "standard" hi-dose preseasonal protocol was modified downward for the next grass season, and no ER visits or oral steroids were needed.  The literature has emphasized the effectiveness of hi-dose preseasonal treatment in the monosensitized individual, but "in the real world of allergy" many of our patients have multiple sensitivities and may respond differently.  Care must be taken!

6.  Multiple antigen threshold dosing for the polysensitized patient, coupled with selected hi-dose preseasonal dosing for a single major allergen works well.  Some patients have sensitivities to dust, tree pollen, mold, etc.  If they are HIGHLY sensitized in addition to a single antigen like ragweed, then the "layering in" of a preseasonal dose of hi potency ragweed treatment on top of polyantigen SLIT can be very helpful.  

In short, this has been my experience with SLIT...I continue to learn...both from the literature and my patients.  And the allergist beginning SLIT in his or her practice will have to do the same.    

How many allergists does it take to change a lightbulb?  Actually it takes 11.  One to change the lightbulb, and 10 to run to the FDA and seek approval for the procedure...One of the biggest hangups in the acceptance of sublingual immunotherapy (SLIT) among my colleagues is that "there is no FDA-approved formulation for SLIT in the United States"  (Cox, Sublingual Im munotherapy:  Review of Clinical Efficacy, Vol 28, pp 162-166, April 2007).  Greer Labs is finishing up phase III safety trials of SLIT and approval by the FDA is  imminent in the near future, in my opinion.  It will be no doubt a relief to all of us that--big surprise here--that it is SAFE to orally ingest what allergists have DIRECTLY  injected into people for decades. We have no problem with injecting a high dose of Ragweed into somebody--no questions asked--but suddenly we'll give them Ragweed orally, and eyes widen in alarm---oh my goodness, this could be DANGEROUS!  In short, many of my colleagues have "hid" behind the lack of FDA approval for SLIT as an excuse for not investigating SLIT...why so?  Why the lack of incredible enthusiasm in a technique shown to help so many people? Why is the glass half-empty instead of half full?  Why have American Allergists been so slow to get going in this area while our European colleagues have surged forward? 

The truth is often ugly, and here we have a good example of it...one difference between the American Allergist and the European Allergist's viewpoint on SLIT is that the American Allergist brings "baggage" with him.  Bad baggage.  At least ONE of the reasons allergists have been unenthusiastic about SLIT ("we need more studies"  "the FDA hasn't approved it" , etc etc etc ) is that  in the 60's and 70's the doctors using sublingual immunotherapy--and saying it worked--belonged to the "Clinical Ecology" movement in the United States.  Shhhhhhh....I'll tell you a secret, but don't say it out loud, OK?  The traditional allergist detests Clinical Ecologists.   And SLIT has at least informally been identified with them.  It will be a bitter pill for some allergists to swallow to admit that SLIT can be an effective therapy.  But the pill must be swallowed...because there are ALOT of lightbulbs out there that need changing...

Ok, I admit it, I'm on a bit of a historical rant...first King Canute, and now St. Benedict.  And no...I'm not trying to have every allergist in the country forgoe their practice and join a Monastery...but there is something to be said about the St. Benedict and the "wisdom of the ancients" that I think is relevant today.  My thoughts on this started out when I saw a new patient in my office recently; she presented to me a beautiful EMR printout from the preceding allergist she had seen.  There it was--beautiful computer template after template of information.  I commented that it seemed like the doctor had been very thorough...she looked at me with penetrating eyes and said "yes, but he didn't LISTEN to me..."

I think allergists at their worst tend to think of our patients as merely "dermal appendages with a life support system attached" to which we apply skin tests.  We seriously study our skin test results, but how seriously do we take our listening?  True Listening (with a capital L) is hard work...but it is so critically  important in our specialty (as well as in every walk of life.)  I had been reading a series of articles on monastacism when the words of  St. Benedict of Nursia, popped out at me in relation to the patient mentioned earlier.  In his Prologue of St. Benedict's Rule, St. Benedict opens with the simple but powerful words "Listen carefully, o son".  

Check out these proverbs on listening, and re-interpreting them from a patient's point of view 

 Proverbs 1:8--"my son, hear the instruction of your father (patient) , and do not forsake the law of your mother..." 

Proverbs 4:10--hear my son, and receive my (patient's) sayings...

Proverbs 19:20--listen to counsel and receive (a patient's) instruction, that you may be wise in your latter days ...

Proberbs 23:19--hear (the patient) my son, and be wise... 

Truly Listening to a patient brings its rewards to the doctor as well as the patient.  We make better diagnoses, and gain better insight into the uniqueness that comes with everyone we see.  Two questions I have found especially helpful in taking a history--and listening carefully to the responses are the following:

1.  "What are your goals that you would like to accomplish as a result of seeing me?"  The answer to this question never ceases to amaze me.  In one patient, who presented with chronic hoarseness, I mistakenly believed her principal goal was to relieve her hoarseness.  Wrong.  Her main goal in seeing me was to be able to sing in the church choir again.  She couldn't do that while she was hoarse.

2.  "What about your allergy condition are you most fearful of?"  One patient recently, with relatively mild exercise induced asthma, seemed unduly anxious.  When I asked this question, she divulged that her grandfather had died from a terrible asthma attack, and she was terrified of the same fate for herself.  

The better listeners we are, the better questions we will learn to ask of patients, and the more we will enjoy their visits.  Talk less.  Listen more.  Remember St. Benedict.  And no, don't enter a monastery...an allergy office is alot more comfortable!