Ever feel like the Odd Man Out? I have. And it's not a nice feeling. I have a painful memory from grade school--sides were being chosen for baseball teams. There I was, waiting expectantly to be chosen. My hopes gradually diminished as all the other boys were chosen, and finally I was left over, with no one wanting me. I was the odd man out. Not a nice feeling, to say the least.

Well, when we think of baseball, what do we naturally think of? Steroids, of course. And who uses steroids the most? Allergists, of course. We have our patients sniff, inhale, swallow, and lather on more varieties of steroids than Barry Bonds ever tried. But all the steroids in the world won't keep us from being perceived as "the odd man out" by our primary-care medicine colleagues.

You see, many allergists today are "the odd man out" in managing the allergic patient--increasingly, everyone BUT the allergist (i.e., the family physician, pediatrician, ENT physician, internist, dermatologist, chiropracter, etc.) get to "manage" the allergy patient, and the allergist is left with empty hands (and an emptier pocket book). Why is this?  Why is the allergist the Odd man out?

Sometimes the truth is ugly. And uglier to face. Getting back to my own childhood experience in being the "odd man out" for baseball teams, I hated the players who were chosen before me, and thought the whole system was unfair. Truth-be-told, I wasn't a good baseball player...in fact, I was a disgrace to the National Pastime. I wasn't chosen because (and get this)--I had nothing to offer either team in the way of talent (or motivation) to make sure our team "won". The Team Captains had nothing personal, mind you, against me--that's just the way they saw it....

Well, how do our colleagues view our specialty? How do they perceive of us?

Easy--just look at the poster picture of 'ol James Mason in the above movie poster. He's a real energetic ball of fire, right? Read the print under the title and picture:  "with his back to the wall, in the tense, taut, tormented role of his life".  Well, Sydney, that's how most primary care physicians perceive allergists.  Don't agree with me?  Then you haven't talked to multiple primary care physicians in quite a while.  Are you furious with the Angry Allergist? Tough.  Get a reality check.  Suck it up. 

Because it's true. 

Here's a thought: maybe the majority of patients don't get an allergy referral from the family physician, pediatrician, or internist because we're perceived of just like I was perceived as a young baseball player--i.e., somebody who doesn't bring a valuable asset or unique talent to bear on the issue at hand.

In order to be a part of the family practice/internist/pediatrician "team" we have to "bring to the table" some tools/techniques/assets to help the patient beyond the usual steroids, antihistamines, etc. that primary care physicians themselves can use. They have to "perceive" of us as offering something more than what they can offer. Then--and only then--we will be "invited to the table" and be part of the team of health care management for our patients. Will an expensive marketing campaign telling patients and doctors that "nobody does it better than the board-certified allergist" work? Of course not. Patients and doctors are too smart for trite platitudes--as one physician assistant told me, he doesn't refer to allergists because he quickly found out that they really didn't offer anything more in the long run than what he himself did medically.

Well, how can we become "a team player" and not "the odd man out?"

For one thing, let's put 5 ideas down and see what shakes out:

1. The Allergist is the odd man out.

2. The internist/pediatrician/family practice community perceive the allergist as not offering anything unique and helpful to the management of their patients.

3. Immunotherapy--something unique that allergists do and is potentially disease modifying--is offered to only a minority of allergy patients by allergists.

4. A safe, effective, painless and convenient form of immunotherapy--if available--could revitalize the allergist's relationship with primary care physicians, and make him a team player.

5.  This form of immunotherapy is already available:  in SLIT. 

I find it incredibly ironic that items #4 & #5 above are being approached by  the American allergy community in an unbelievably overcautious, defensive posture.  Hey guys--get real--this is the ONLY thing that has a chance to revitalize our sick profession.  We'd be able to offer more patients safe effective treatment (Sublingual immunotherapy, i.e., SLIT)--which is something that the average pediatrician, internist, or family physician can't do.  Now THAT could engender referrals better than any slick Madison Avenue Campaign.  In short, SLIT can in my opinion completely revitalize an allergy field full of tired old symptomatic treatment with inhalers, antihistamines, and creams.

We should be falling all over ourselves doing American-based studies, and promoting SLIT. I mean we should be so manic about this topic we should be SICK of it.  After all, can over 100 European studies on SLIT be wrong? 

So, we have a choice as allergists:  Develop ourselves into a specialty that deserves referrals from primary care physicians.  Develop and enhance immunotherapy protocols--specifically SLIT--and do more of what should really define who we are:  immunotherapy.  Or...continue to push the latest inhaler du jour, the most brightly colored antihistamine,  and remain...the Odd Man Out.    As for me?  I've been Odd Man Out once in my life--and once was enough.  

Later, Dude