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An Open Letter to a Young Allergist...

Congratulations!  After two years of Fellowship Training, you're about to be done...and be certified as an Allergist.  The whole "World of Allergy" awaits you...and you're about to take the big step forward into directly caring for patients on your own...As someone who has been "in the trenches" for nearly 30 years in treating allergic diseases, I have a few words of advice.  This letter could be entitled many things, but perhaps the best title would be

"Mistakes I've made and Lesson's I've learned"

For you see, I've found that not everything you've learned in your training program applies to the Real World of allergy. Naming and learning leukotrienes is one thing, but dealing with patients is quite another...Here are some things to think about when you begin to see patients--lessons I've learned in the last 28 years that have helped me in my practice:

1. Lesson 1: In the Real World of Allergy, patients don't give a damn whether they're sick because it's "IgE-mediated allergy" or not--they just want to get well. You'll see many, many patients with adverse reactions to foods and molds where your prick test is negative, and telling the patient "they don't have an IgE mediated allergy" is very cold comfort to them. They want answers, and telling them what it ISN'T is not nearly as satisfying to the patient as telling them what it IS. A practical point--they're not likely to refer you a whole lot of future patients, either. Here's the clinical pearl: In the Real World of Allergy, you've got to get comfortable with non-IgE mediated reactions--and fast--if you want to be a superior allergist...

2. Lesson 2: You've got to get experienced in delivering immunotherapy regularly in your practice, and preferably in a well tolerated, safe and effective form: SLIT. If the only thing you're interested in is treating asthma and allergic rhinitis with only drugs, you'll be a very lonely--and poor--Allergist. Face it: we have alot of competition for treating the asthmatic patient, and the allergic rhinitis patient. We've got good symptomatic drugs too--which the family physician and pulmonologist and otolaryngologist can all deliver. You've got to deliver something the family physician and the pulmonologist and the otolaryngologist can't deliver--and that's immunotherapy. SLIT is the wave of the future. Bone up on it. Fast.

3. Lesson 3: There are other things in the Allergist's life besides asthma. Open up your vistas, and start thinking of ALL mucosal organs (and the skin) as targets for allergic disease. Our professional societies have done a good job at "marking our territory" as asthma--that's all well and good, but you'll see plenty of patients with urticaria, migraine headaches, fatigue, and other issues besides asthma. Many of these patients come with a mix of IgE and non-IgE mediated illness. In truth, the allergist who only treats asthma is like the musician who only plays one song: It gets pretty boring, and is an incredible waste of talent...

4. Lesson 4: Revel in the mystery of allergy--and develop your sense of curiosity in your practice. Just because we can't EXPLAIN a patient's reaction in terms of what we presently understand from our training program, there is no need to deny it exists or delight in the mystery of how it happens: Why does Mrs. Smith get tired shortly after eating wheat products? Why does Mr. Smith get a headache 12 hours after cleaning up a moldy basement? Why do Mr. and Mrs. Smith have negative prick tests and IgE negative RAST tests to wheat and mold? There is a subliminal tendency in many young allergists to not be interested in anything they can't explain. An observation is DENIED because the PATHOPHYSIOLOGY is unclear. That's backwards. It is the patient reactions we can't explain that should interest us the most! Thinking should begin with the NEGATIVE prick test and the NEGATIVE RAST test...not the positive ones. There are many, many, things we do not understand about how food and aeroallergens affect the patient, and the sooner we humbly acknowledge this, the better. This is the "Grand Mystery" of allergy. Accept it, embrace it--and study it...

Keep these four lessons in mind as you start your practice--you'll have a satisfying and rewarding practice for many years to come.

Later, Dude


Posted on Monday, May 25, 2009 at 12:34PM by Registered CommenterGeorge F Kroker MD FACAAI | Comments1 Comment

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Reader Comments (1)

Hi, Dr. Kroker. I follow your blog regularly. I especially like to read about some of your interesting cases. I work for a company called AchooAllergy and our web site is www.achooallergy.com. I was wondering how you would feel about allowing me to reprint your letter to a young allergist on our blog next Wednesday, June 16th. We have guest bloggers and we usually run a picture and link back to their sites. Would this be something that you would be interested in allowing us to do? Please e-mail me at your convenience. Thanks.

June 8, 2009 | Unregistered CommenterJamie

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