Whew!  I can finally relax...our annual SLIT meeting to train physicians in the use of sublingual immunotherapy (SLIT) was a success...It was obvious to me (as my colleague Dr. Mary Morris once again reviewed the world's literature on SLIT at our meeting) that an astounding phenomenon appears to be shaping up:  Most allergists now admit that SLIT works--in Europe.  Europe only.  Somehow they feel (by implication) that it just doesn't work in the U.S. What else could explain the extraordinary lack of interest in SLIT by my fellow U.S. colleagues?  (laziness is always a possibility, but let's not go there...)

For example, take simple cat allergy--one of the only allergens comparatively studied for SLIT efficacy in both the Europe and the U.S.  :  it seems to work in Europe but doesn't work over here--in the U.S. study by Dr. Harold Nelson published in the JACI in 1993, it was concluded that SLIT for cat was no more effective than placebo. On the other hand, the European community, represented by Dr. Alvarez-Cuesta and associates, publishing in Allergy in July 2007   found that SLIT for cat was effective. What's the deal?  Over and over again we're hearing about European success with SLIT, but NOTHING from the U.S.  Nada.  Zero.  Null set.  Zip.  Zilch.  What could be the culprit?  Well, I've got the answer and it's a slam-dunk:

The Atlantic Ocean.

Yep, you've got that right.  It's the only logical conclusion. If it can sink the Titanic it can sink SLIT... Something in or on or above the Atlantic Ocean inactivates the effectiveness of SLIT as it migrates from the European to American continent.  Furthermore, this unidentified factor (we'll call it Sublingual Neutralizing Ocean Transatlantic Factor--SNOT for short) not only inactivates SLIT's effectiveness, but also renders American Allergists intellectually moribund in thinking about SLIT--we cop an Attitude:    "Well, the SLIT evidence is from Europe, and we have to see U.S. studies...we'll get around to them someday...but what's the rush?"   

So what can we do?  Some say we should perform U.S.  studies on SLIT and get the show on the road....well, I say--how about isolating SNOT--finding out exactly what it is about the Atlantic Ocean that makes SLIT migration from Europe to the U.S. so disastrous...you see, this would be helpful for one big reason...

...we could then make a DRUG against SNOT...and pharmaceutical companies could cash in...and that's really the point of medicine, after all, right? 

So, let's get the ball rolling...SLIT works in Europe but not the U.S.  Why?  It crosses the Atlantic Ocean and voila!  Poof!  Disaster!  So let's analyze and study and plumb the ocean's depths to find out what the Sublingual Neutralizing Ocean TransAtlantic (SNOT) factor really is, and why it keeps SLIT from working in the U.S. and stagnates American Allergists minds against exploring its effectiveness.   How about a full issue of JACI devoted to this?  Let's get some major drug company sponsored money for goodness sake to look at SNOT receptor antagonists.  C'mon guys! 

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

Well, judging from my last entry, you are probably wondering what I feel the best EMR is.  That's not hard.  This one's a beauty, and I've been using it for years without problems.  It is the best EMR--bar none.  Check this baby out:  ...it has an unbelievable boot-up time, and never suffers a power outage...battery life is fantastic and read/write time is great...

Right now  I'm using the above computer ALOT to prepare my talks for the upcoming SLIT conference we have this week.  Oh, by the way, I DO use powerpoint also, but believe me, this older baby still rocks...

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