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.

Ever have a really good idea--I mean an idea that actually gets better the longer you think about it?  If you're like me, ideas like that are few and far between.  For me, they usually occur in the one spot I'm never bothered, and never harried--the shower.  The last really good idea (like those rare, really GREAT ideas I mentioned before) was "I'll think I'll go fishing in Canada."  Now that turned out to be a really good idea.  Anyways, (and I'm getting to my point) I happened to have another really good idea recently.  It all started while I was showering, and thinking about how accustomed (we) allergists are   to receiving brochures on numerous allergy-sponsored activities, including asthma camps, asthma support groups, and of course asthma poster contests.  These are usually met with much fanfare, as is everything having to do with asthma.  Poster contests for various diseases abound.  The AAAAI, for example, has sponsored a national asthma poster contest.  And then it occured to to me: what about the poor allergist...is he/she to be denied a poster?  Then one of these REALLY good ideas hit me like a lightning bolt:

What if we had a poster contest just for the ALLERGIST? 

How about a contest for a poster that epitomizes the American allergist and his current "state of the art" philosophy on the diagnosis and treatment of allergic disease.... Something that would truly symbolize the typical allergist's interest in allergy as it affects the entire body, his curiousity and open-mindedness for non-IgE mediated sensitivities, and his curiosity and openmindedness for new therapeutic options like SLIT, etc. etc. etc....Why couldn't allergists design their own poster--after all as our official socities have proclaimed in a common platitude--"nobody does it better than the allergist?" Right? 

In pondering such a poster,  some thoughts immediately came to mind.  But before I go further, I must mention that what I tell you is possibly offensive, and therefore this particular journal entry comes with a black box warning. 

Yep, you heard me right Sydney, a black box warning.  And you know what?  I'm surprised somebody hasn't already thought of black box warnings for blog entries.  I personally think its a killer idea.  You know, it seems these warnings are becoming more and more common on meds, and therefore why not on medical blogs?  It's merely a safety issue, to protect you, my dear readers, from unanticipated--and possibly hazardous--side effects.  After all, If it's good enough for protopic & elidel, (and Ketek) then its good enough for  the Angry Allergist Blogs.  So expect to see more of these as time goes by on my blog.  So here it is below--please read it and ponder before going any further, and remember this is offered as just one more service by the angry allergist.  (An aside to bloggers--feel free to cut and paste this warning for your own journal entries if you want! I'm waiving copywrite on this! )

So if you read this black box warning and want to skip this entry, just click out now on this link , and I won't be offended in the least.  Otherwise, knowing the risks, you may read on below:

 First Annual Allergist Poster Contest

The following are the 3 finalists in our choices for Winner of the First Annual Allergist Poster Contest.  Please feel free to vote for your favorite by emailing me.  We'll be counting them soon, and the first poster to get 100,000 votes wins...!

       ENTRY #1                       Entry #2                     Entry #3 

I know, it's soooo hard to make a choice...but give it a try.  Personally, I am leaning towards entry #1, but I realize you may have a different preference.  But no matter.  The best thing about it is (you guessed it) no matter WHICH ONE you choose... (dare I say it?) you can't go wrong!  So stay tuned!  Find out who wins...and see which new blog entries merit black box warnings!  What more could you want? 

It's Wednesday morning at 10:15 AM.  And you're sitting in your allergy office with Mrs. X, a doctor's wife.  Frankly, you'd rather be somewhere else.  Anywhere-else.  In fact, very frankly, you'd like to be as far away from Mrs. X as humanly possible.  Because Mrs. X. isn't an atopic patient loaded with IgE.  And that means only one thing:  Trouble--trouble with a capital T. 

When Mrs. X. presented to your office yesterday, she complained of seasonal chronic sinus congestion in the spring and in the fall.  So you  tested her and found negative prick tests to all allergens, but just to "make sure" you had done some ID's to molds as well.  Fortunately, she had only a slight reaction which you told her was "insignificant"--you were secretly glad because you knew that injection immunotherapy doesn't do squat for mold allergy anyway.   You confidently told her that she "had no allergy", gave her the latest, greatest flavor-of-the-day nasal spray with the most colorful box you could find, and sent her on her way, reassuring her that all was well.  After all, you'd get reimbursed for the skin tests by her insurance company, and she got a free nasal spray sample out of it as well.  Life is good... Schazam!--Another case solved...

Then, unfortunately, she called you back early this morning, and that's when the problems began... after leaving your office she said later that evening she began to notice some  "strong reactions" at the sites of some of her former intradermal mold tests; they continued to grow overnight and now she feels miserable today after her prior testing the day before. In fact, she feels exactly like she feels during a bad day in the spring or fall mold seasons.  So she's now back in your office demanding an explanation as to what these events mean, and expects you to treat them.   

So now what?

Near as I can figure, you've got  3 choices on what you could do at this point: 

a:  you could let your p.a. see her and duck out the back door

b.  you could tell her that "we don't know what the "late phase cutaneous reaction" (LPCR) means" and ask her what she's got against using the latest & greatest nasal spray you gave her yesterday--and lay a heavy bill on her for good measure

c.  you could explain that her LPCR's mean she is a delayed reactor, explain the nature of her symptoms--that they correlate with the time course of the LPCR-- and treat her effectively with SLIT

If you scored "c" you're the sharpest tool in the shed.  Because SLIT works for LPCR's.  And I mean it really works... But to do SLIT on LPCR's you first have to get an idea of "how strong is strong?" for the LPCR.  You need to calibrate it, through doing three very basic things:

1.  Do repeat testing with serial IDT on the items she had LPCR to.   

2.  Observe at 12, 24, 48 hours.

3.  Start SLIT at the strongest IDT titration that is negative for LPCR.  That is, if she had positive LPCR's which swell at 24-48 hours on dilutions 2 & 3, and none at 4, then start SLIT at 4. 

Never "buildup" or give "high dose" SLIT treatment (like the European preseasonal rush protocols) to a patient with LPCR's and no immediate skin test positivity.  European preseasonal rush protocols work great for the atopic patient--I've done plenty of them--but they spell disaster for non-atopic patients with LPCR's.  When treating the LPCR, only go stronger on SLIT  if you repeat the testing first, and firmly establish that a higher dilution now causes no LPCR like it had previously done on earlier testing.  Only then can you could step up to the next higher dilution.  Remember:  this isn't IgE mediated sensitivity.  You don't need high dose treatment.  Low dose treatment at the threshold of the LPCR is enough. 

As mentioned earlier in this series, SCIT (not SLIT) for patients with immediate AND delayed reactions has been shown in 4 controlled trials to result in a reduction in delayed reactions.  SLIT does the same.  However, for patients with no immediate reactions, but a strong LPCR, SLIT is the way to go. You can successfully treat these patients. Over the years I've effectively treated LPCR's to dust, mold, and the occasional pollen that gives strong LPCR's but no immediate reactions--all with virtually no side effects and great clinical response.  Generally, over time, when repeat testing is done in a patient on SLIT, a reduction in LPCR's occurs, as evidenced by observing stronger IDT dilutions required to have any LPCR at all. 

And it works.  Believe me, dude, it works. 

I've been using variations of this approach for "problem" patients like Mrs. X for 25+ years, and I've found SLIT is the only thing that effectively addresses LPCR's to molds, dust, or pollens when there is a minimal immediate reaction or none at all, and the majority of the reaction is delayed.  And patients love it.  I love it because I no longer dread seeing Mrs. X.  And Mrs. X in turn thinks I  walk on water and sends all those atopics to me that I so lust after.  And life is good afterall...