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"Curiosity killed the cat" but...

   I hate complainers.  You know, the kind of person who just only complains--and doesn't offer a constructive solution to the problem at hand...  In my last journal entry, I pointed out  I felt allergists had "lost their way" and that simply training more allergists is a superficial solution to a much deeper problem.  "Fine", you say, "you've talked about producing better allergists--not more allergists--but how do you define a better allergist?"  That's a long answer I hope to delve into in my journal over time, but one essential element of a good allergist is, quite simpy put: curiosity.  And curiosity amongst practicing allergists in my opinion is unfortunately in very short supply...in shorter supply, in my opinion, than the number of allergists being predicted for the near future...

"Curiosity killed the cat" may have first been coined by British playwright Ben Jonson in his 1598 play, Every Man in His Humour.  I have a new phrase I'd like to coin, but I doubt it will be as popular...

"lack of curiosity is killing the allergy profession".  Not as catchy as old Ben's proverb, but it works for me.  And I sincerely mean it. No curiosity.  Nada.  Zippo.  Null set.  I mean, a dead rabbit has more curiosity than the average allergist.  


 

An English country doctor, Edward Jenner, made a simple observation:  milkmaids getting cowpox did not get smallpox.  Edward_Jenner2.jpgThen, being curious, he asked himself why they were protected from smallpox by having had cowpox. The rest (as they say) is history....

 

As a consulting allergist in clinical practice, who often sees patients from other allergists for a "second opinion", I often think that the critical difference between making the proper diagnosis and the wrong one is simply a matter of...curiosity.  

When a prick test to ragweed  is highly positive in someone with seasonal fall allergy symptoms, any monkey can make the diagnosis of seasonal allergic rhinitis in a patient.  But when the prick test is negative, then that's when we should be curious...and we should start thinking...in truth, most patient's are told they "have no allergy" or "the prick tests are negative" or they have "nonallergic rhinitis", and that's that.  End of story.  No further testing.  No curiosity.  No interest.  The patient gets shipped back to the primary care physician with the nasal spray du jour, perhaps garnished with a an antihistamine and a  sprig of leukotriene blocker thrown in for relish.  Let me give you an example from my own practice where the testing didn't fit with the history, so I got curious

 Patient X calls and requests to see me.  She had been diagnosed as having severe tree pollen sensitivity--especially to birch pollen--by another local allergist.  She would get severely sick each spring in April.  She had not been given immunotherapy for her problems (remember in my earlier journal rantings what I said about the typical allergist being an inhaler jockey instead of doing what they do best--immunotherapy?)  , despite being sick each spring.  She wanted to come in to see me for sublingual immunotherapy (SLIT) for birch. So she came down to see me in July, after the season was over with.  SLIT works like dynamite for birch desensitization.  Anyway, there was only one problem with her trip down to see me--she suffered a severe attack of spring hayfever symptoms while driving down to our clinic in La Crosse.  Except it wasn't springtime, and there was no tree pollen in the air.  None.  Although our testing confirmed a strong birch sensitivity, her grasses and molds were entirely negative.  So I got curious. I delved into the nature of her drive down to see me--she had driven from South Dakota on a windy day past some rapeseed fields..and began to get sick.  It turns out rapeseed (Brassica napus) pollen can cross react with Birch pollen--i.e., the identified allergens in Brassica represent cross-reacting homologues of well-known pollen allergens.  I personally hadn't known this, but learned from the patient's history, and didn't dismiss her history or my physical exam of her simply because it didn't "fit" with what I already knew.  In this case, curiosity helped me.  Greatly.  

So what should the practicing allergist be curious about?  In short, everything you can't easily explain.  And the things that patients are usually curious about aren't what we as professionals, are necessarily most curious about.  For example, I've never had a patient in my exam room query me with "Doctor, do you really think that changes in Il-10 play a key role in the effectiveness of SLIT?"  Here are some questions that should make us curious, all of which I've encountered in my own daily practice: 

1.  "Doctor, my arm tests really swelled up the next day.  I know you told me I'm "not allergic" because I had no immediate reaction on my skin testing yester, but I feel really sick today--headache, feverish, aching, and my arm is all swollen up.  (curiosity cue for us:  That's not normal.  What's going on?)

2.  "Doctor, I took a fluconazole tablet from my gynecologist, and my vaginitis went away, but for 24 hours my sinuses totally cleared up--for the first time in years. Then they closed again..what happened?  (curiosity cue for us:  can an antifungal medicine for vaginitis effect the sinuses?)

3.  "Doctor, I was out with my biology class collecting mushrooms in the dirt, and immediately afterwards I had sneezing AND intense vaginal itching?  What's going on?  (curiosity cue for us:  thinking about the vagina as an allergic organ)

 Every residency and fellowship training program in allergy should encourage curiosity, and even controversey in my opinion.  Have debates (pro and con) formally set up about controversial topics--provocative neutralization, kinesiology, alternative food tests, and really check the literature and force a pro and con debate between the sides.    And take patient-based questions  that we are uncomfortable with, and face them--Not ignore them and  place under them under the convenient euphemisms of:

"non-allergic." (and therefore I have no interest in it)

"that hasn't been proven to be effective" (and I therefore have no interest in it)

and the best one of all--go back to your primary care physician; your skin tests are negative (and I have no interest in you or your problems). 

I'll conclude with a quotation from last week's JAMA, in which the book "Happy Accidents:  Serendipity in Modern Medical Breakthrus" is discussed on p 1832: 

           "The focus in medical schools and higher education institutions in the field of science is on facts, not ideas; on outcomes, not process..Their curricula completely ignore the process of how discoveries and current concepts come to be accepted.  Lacking is any sense of awe and wonder for the magic of discovery, and there is little attempt to teach, or even encourage, the kind of creativity and complex synthesizing of ideas that has enabled discoverers to connect the dots that led to major breakthroughts in understanding (p 313)"

So I feel we are really facing an allergy/asthma crisis--in curiosity.  And the sooner we face this, the better.  More curious, creative brains in our field are needed.  Raw grey matter is not enough.  And I'll be curious to see what the future holds for our specialty...
 

     
 

 


 

 

Posted on Wednesday, May 2, 2007 at 05:23PM by Registered CommenterGeorge F Kroker MD FACAAI in | Comments1 Comment | References1 Reference

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hiya


Just saying hello while I read through the posts


hopefully this is just what im looking for looks like i have a lot to read.

July 30, 2010 | Unregistered Commenterkneedgeroasse

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