Look at the following picture (the little rectangle) to the left.  What do you see?  Carefully analyze it, study it; if you want you can even take it home at night and pour over it and see what you can come up with.  Puzzled?  What if I showed you another "bigger picture", this time with the above picture included?   

We have all failed to see "the forest through the trees"--it's part of our human frailty.  But allergists, in particular, are prone to an even bigger problem. And once again, this is where I'll insert my notorious "black box warning", since what I'm going to say may upset quite a few of you...

Allergists (in my humble opinion) are prone to "over analysis syndrome" .  Big time.  We often fail to "put the pieces of the puzzle" together in complex allergic patients.  We are so busy minutely studying the immunological "bark on the tree" that we fail to see the "forest"--i.e., the "big picture"...

Just look at our medical journals...elegant papers are written on exotic immunological aberrations; but it seems that nowhere do we have practical case studies or examples of how to approach or treat the truly difficult allergy patient with multiple sensitivities to foods, inhalants, chemicals.  Oh sure, we have published case studies on rare (usually isolated) allergy sensitivities, and case studies on difficult to manage asthmatics.  But where do you find the case studies on patients with multiple food and inhalant sensitivities affecting multiple body organs?  Where are the  algorithms on how to approach this type of case? 

Allergists like their immunology hard and their patients easy.  We like to see patients with only one body organ affected (the respiratory tract if you please) and certainly not more than one (and certainly not more than two) major sensitivities (if you please).  Nothing difficult.  It would be too taxing.  We might break out in a sweat. 

In our Annual sublingual SLIT symposium  the favorite talk I give is "How to Approach the Difficult Patient".  I could just as easily name this talk "Lessons I've Learned and Mistakes I've Made", since allergy diagnostic synthesis is something not taught in allergy fellowships.  And that is a tragedy.  I could also have named this talk "An Engineer's Guide to Allergy Management" since as a former electrical engineer (BSEE) I approach allergy from a "systems viewpoint" with an eye towards synthesis. 

Synthesis:  It's a word you'll NEVER hear at allergy conferences.  But analysis?:  Allergists do so much over analysis we ought to enter rehab.  But analysis is only productive when performed with an eye towards synthesis....And so my next journal entries will focus on patterns I've seen in my allergy patients over time, with an eye towards synthesizing the information into a coherent whole.  Taking the dizzying array of problems in the polysymptomatic patient and making sense of it all--in short, synthesizing something diagnostically coherant from apparently scattered clinical symptoms and signs.    The sum is greater than the parts...and that goes for allergy, too.

Later, dude.