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 

Chances are most of us got to work today in a car.  My car is a modest Honda Accord.  Gets the job done.  But if I was 'ol Bubba, I'd want a big 4x4 with a gun rack and probably the capability to get thru some bad gullies to my deer stand...right?  Well, the car makers got it right.  They design cars for different purposes.  It's a versatile form of transportation. But different cars "work" for different people.  We all "know" that, right? 

 Which gets me to SLIT. 

You see,  what's really missing in every one of the papers published on SLIT is perspective. Oh sure, we talk about its safety, its effectiveness, and its convenience.  But I've used SLIT as my technique of choice for immunotherapy for over 26 years--and I'd say the biggest advantage of SLIT can be summed up in one word:

Versatility.   

Huh?  What?  

SLIT can be used via a number of specific techniques, depending on the clinical situation;  in my use of SLIT for a quarter century, I've found it useful in 5 different ways:

1.  Multiple antigen threshold dosing (via IDT) for multiply sensitized patients who have chronic perennial symptoms from multiple allergens--dust mite, dander, molds, etc.  Believe me, you'll get into trouble when you try to escalate Ragweed in an unstable chronically allergically-reacting perenially sensitive patient who is reacting day-to-day to dust and danders.  Been there.  Done that.  But multiple-antigen threshold dosing is dynamite. 

2.  Working off the delayed reactions to mold, treating with low dose threshold dosing for delayed mold reactors.  i.e., reading the delayed wheals the NEXT day, and  treating off the strongest negative delayed wheal (via IDT) in people with little or no immediate reaction to molds, but strongly positive delayed reactions.  Works like a charm.  This advantage along would make SLIT "worth it" to consider.

3.  Prerseasonal rush immunotherapy for monosensitized patients who have an isolated pollen allergy, used via the European tradition.  Adopting the European tradition for Parietaria pollen to Ragweed, for example, works great. 

4.  Modified IDT-based rush immunotherapy for mold allergic patients, using a protocol recently discussed by Saporta & McDaniel in ENT Journal August 2007, pp 493-497.  This works well for Alternaria mold in my experience, while traditional preseasonal rush via the European tradition gives more side effects and is tricker for molds than for pollens.  Starting with a dilution #4 typically for Alternaria, then moving to dilution number 3, sequentially as McDaniel describes works great in the winter "off season" when Alternaria isn't around.

4.  Traditional build-up dosing for patients with severe IgE-mediated food allergy to peanut and other severe food allergies.  Starting with several nanograms of peanut (a number 9 IDT dilution typically), and slowly working up in a conventional "build-up" manner works well.  

These techniques all work.  And I laugh when I read articles and commentaries in the current allergy literature discussing "what's the best dose for SLIT?" which seems to be the current "debate du jour" for SLIT.  You see, it's really quite simple:

The best dose for SLIT depends on the type of allergy patient being treated.  Any attempt to find a "universal, standardized protocol" for SLIT to cover all types of allergy patients is absurd. 

A reader of my blog wrote to me expressing this sentiment (and his frustration):

 "The AAOA is talking about a SLIT protocol that abandons 40 years of quantitative testing tradition when dosing for SLIT--one size fits all, rapid escalation, wait until you have a reaction to back it off.  How can this be?" 

 

All I can say is, "I hear ya, pal".  It's absurd to suppose that a "universal" SLIT protocol can be found that will be appropriate for all patients.  The Holy Grail will never be found.  To have a single protocol for SLIT immunotherapy makes about as much sense as an Infectious Disease doctor having one dosing protocol for an antibiotic (doxycycline, for example).  Doesn't it make sense the dose and schedule depend on the infection and the status of the patient?  Well, it's the same for SLIT folks.  The dose and the duration depend on the immunological status of the patient. 

My suggestion?  Simple:

Before the AAOA comes up with any protocol, have the AAOA do some real research and digging...and talk to some of the "experienced clinicians" who have been out there using SLIT for years.  Our own clinic has over 100 years of SLIT experience divided between the 6 physicians in our clinic.  We've made alot of mistakes, and alot of "blood, sweat and tears" have gone into  coming up with protocols that finally work for our patients.  We teach these protocols at our annual SLIT conference.  And the attendees have come back to us year after year, and gratifingly have said our protocols work. 

Final thought?  I don't want the AAOA to have to go through the same mistakes we've made.  Because I care about the AAOA...and I care about my patients.  SLIT is versatile.  And it's just too plain and versatile a tool to hamstring to "one universal protocol"  In cars, one size doesn't fit all.  And the same holds true for SLIT.

Later, Dude.