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.