A voice for reform in the field of allergy...You're entering the no-spin zone of the Renaissance Allergist...Straight talk by an allergist seeking reform in his renaissancepicture3.jpgprofession and a renaissance in the field of allergy...


On the "iPatient"....and the EHR

I sat in the exam room, looking across the table at Madelyn.  In front of me was an immaculately printed electronic health record (EHR). 

"This is quite a medical record", I said to Madelyn as I reviewed page after page of  printout, "it looks like the doctor was very thorough..."

Unknowingy, I figuratively had walked into a propeller blade...

Madelyn's face and tone flared angrily..."Thorough?" she said.  "He didn't even listen to me".  He was more interested in the record than my problems!

True enough, page after page of print-out was computer generated, and on a second-review of the records, I found I was actually reading boilerplate printouts and was struggling to  to find out what the doctor was really thinking.  

One caveat I must mention at first:  We use an EHR in our office, and there are many advantages to doing so.  We have a good EHR. And yet, the EHR poses a hidden danger for physicians in general, and allergists in particular.  These concerns are often swept "under the rug" in the ongoing enthusiasm over EHR's.  

1.  EHR's are ideally suited for the single-problem, fixed-onset, acute illness.  In that respect, emergency visits to the doctor can readily be translated into EHR "speak":  Broken leg.  This AM.  Pain on movement.  Etc.  However, when a patient comes into the office with chronic, multiple complaints, it's an entirely different story. History taking for the chronically ill, polysymptomatic patient is a messy business.  In this situation, patient's don't "speak template" to the EHR in an orderly and disciplined fashion. In a highly charged emotional atmosphere and seeking help desperately, I find they often can ramble, get times and dates mixed up, retract prior statements, add crucial pieces of information about one problem when talking about a completely different problem, etc.  A simple question like "when did your asthma begin?" might first elicit a response like "when our daughter Elmira was pregnant".  

When I'm taking a history on such a patient, I use a simple pad and paper.  It works for me.  I jot down "sound bites" as they occur from the patient, and organize the jumbled collection of info with arrows, circled statements, etc.  Templates, check boxes, bullet lists, drop-down menus are for later.  In short, patients present their data to us in analog fashion, and the EHR wants it in digital fashion.  There's a difference...

2.  The allergy history is about one thing...relationships.   Relationships between the patient and...diet, biological aeroallergens, chemicals, hormones, etc.  EHR's are patient/body centered.  An allergy history is relationship-centered.  There is a cataclysmic difference between the two.  The EHR may print out a diagnosis of "Bronchial Asthma", but the real diagnosis might be "bronchial asthma seriously exacerbated by indoor air quality impairment in a home from mold, complicated by a hidden milk allergy.  Try to find a drop-down box for that!  

3.  The EHR doesn't like "open ended questions".  It's hard to find a checkbox for them. There's a danger in "thinking like the EHR" and becoming more computer-like in your history taking, limiting questions to digital "yes or no" responses.  Some of my favorite questions for patients include things like "Have you taken a trip recently, and (if so) did you feel better and (if so) what was different about the trip?"  "Have you noticed feeling any different when you went on a weight-loss diet, and if so, tell me what was different? etc. etc. etc.  

4.  Listening is an active, difficult process for the physician.  It takes all of our concentration. Not 90%.  100%.  What is this patient actually telling me?  What does their body language tell me?  With the EHR, clicking boxes and using dropdown menus means there is a subtle temptation to be "documentors" first, and "listeners" second.  It must be the other way around.  We have to constantly guard against this temptation.

5.  One other temptation:  staring at the computer screen instead of the patient.  Eye-to-eye contact can be diminished.  Does the patient sense we are spending more time with the computer than themselves?   

As one physian stated in a recent op-ed piece in the New York Times, we are  creating "iPatients" with the EHR.   The danger is thinking that the iPatient is "the patient".  There is no drop-down box that fully explains a patient's issue of not taking immunotherapy because they were too busy caring for their terminally ill mother who has cancer, and their anxiety and depression related to their situation.   

So for Madelyn, she perceived that the other allergist had made her into an "iPatient" and not a true "patient".  The challenge for allergists is to use the EHR as a tool, and not an end-in-itself. Filling out a good EHR but not listening to the patient's concerns is like a student answering the questions on their paper but not understanding the assignment.  The result?  A EHR with massive boilerplate printout full of Sound and Fury, but signifying nothing.  Me?  I'll keep using the EHR...but with a good paper and pen in-hand also.  The EHR doesn't think.  I do. Sometimes we forget that.

Later, Dude

Posted on Sunday, March 20, 2011 at 11:59AM by Registered CommenterGeorge F Kroker MD FACAAI in | CommentsPost a Comment

Sublingual Immunotherapy...a Pipe Dream?  

"......Just as I am affected by the maniac, so I am affected by most modern thinkers....I hear also from half the chairs of science and seats of learning today; and most of the mad doctors are mad doctors in more senses than one.  They all have exactly that combination we have noted:  the combination of an expansive and exhaustive reason with a contracted common sense.  They are universal only in the sense that they take one thin explanation and carry it very far.  But a pattern can stretch for ever and still be a small pattern.  They see a chess-board white on black, and if the universe is paved with it, it is still white on black.  Like the lunatic, they cannnot alter their standpoint; they cannot make a mental effort and suddenly see it black on white..."

--G. K. Chesterton

Sometimes I wish our own allergy socities were flexible enough to occasionally look at things from both perspectives, and not just one.  Things can be both "black on white" and "white on black".  Recently I received an email to ACAAI members by our President, Dr. Dana Wallace.  She gives a nice summary to the updated "Joint Task Force of Practice Parameters" with one exception:  In discussing SLIT, she says (and this is a direct quote)"

"However, without any FDA-approved product, it is, at this time, only a pipe dream for the U.S.".  

What?  Pipe dream? SLIT utilizing FDA-approved extracts is simply an "off label" use--and perfectly legal.  Let's look at the definition of "pipe dream" .  Maybe Dr. Wallace knows something we don't.   Here it is:

    "a fantastic notion or vain hope"  "a fanciful or impossible plan or hope"

Is this where SLIT is in the eyes of our allergy leadership? Let's look a bit more into the origins of where the notion of the phrase "pipe dream" came from...

The phrase "pipe dream" has been in use for over 100 years.  The earliest use is probably posted in the Chicago Daily Tribune in December 1890, stating that

"it (aerial navigation) has been regarded as a pipe-dream for a good many years..."

In reality, the phrase probably has its origins in the dreams experienced by smokers of opium pipes.  The first association of the phrase with opium smoking is from The Fort Wayne Gazette in September 1895.   In essence, if you were smoking opium you had crazy dreams...a "pipe dream".  

So are those of us who use SLIT effectively in our practice simply experiencing crazy dreams?  Are we smoking something we shouldn't be smoking?  I think not.  This coming month, I'll be giving a lecture in Phoenix Arizona on "Thirty years of Sublingual Immunotherapy".  The title of the lecture says it all.  

But our allergy leadership doesn't stop at just calling SLIT a pipe dream.  Get this:  it opens up injection immunotherapy to children under the age of 5!   Was the allergy community wrong all of these decades in discouraging its use before age 5?  Have they admitted an error in their thinking, or were they right all along and being cautious with a protentially fatal treatment?  Where is the logic in their current decision?  A more logical approach would be to call for additional studies utilizing SLIT in very young children since this seems such a vastly safer treatment.  Why not establish a priority in funding such studies?  Instead we take the same tired injection technique and "force it" into a wider audience.  The chessboard remains white on black.  Never to change.

So is SLIT a "fanciful or impossible plan or hope"--a "pipe dream"?  No.  But I seriously wonder sometimes what some of my professional colleagues are smoking.

Later, Dude 





Posted on Wednesday, February 9, 2011 at 12:21PM by Registered CommenterGeorge F Kroker MD FACAAI in | Comments3 Comments

The Tale of Two Sisters

As I opened the exam room door, Abbey and Annie were sitting together.  I always enjoyed seeing them.  They seemed inseparable...two sisters who loved to be together and enjoy each other's company.  They had come in a few years ago with similar problems...allergic conjunctivitis and mild perennial congestion with seasonal exacerbations in the spring.  They always preferred to be in the exam room together, and I thoroughly enjoyed seeing them. Not surprisingly, they had similar sensitivities:  inhalant reactions to dust and pollens, and both had a mild milk allergy.

I had placed them both on SLIT, and they had both responded nicely.  But this time as I walked into the room and shook their hands, I sensed immediately that something was terribly wrong.   Abbey was her usual bright and sparkling self, but she shifted her eyes towards her sister, who had a dull, morose expression. I began speaking to Abbey, who seemed more open to talk, and I hoped that would "break the ice" with her sister, who seemed quite withdrawn.

"Abbey", I said, "it's been a while since I've seen you both.  How are you doing?"

"Really pretty good, considering the stress I've been under.  I've lost my job, but am looking for another."

"I'm terribly sorry to hear that.  Stress can really aggravate an allergy condition.  How have you been doing?" I asked.    

"Really pretty well despite everything going on", Abbey said.  "I had some minimal eye itching this spring, and my congestion is under good control.  I haven't needed my antihistamines." 

"That's great", I said.  "Have you been taking your drops?  

"Yes I have.  That's the one thing I've done despite losing my job.  I haven't been too good with dairy restriction though, but it doesn't seem to really bother me."

After further assessing Abbey, I turned my attention to her sister Annie...

"Annie, how have you been doing?"  I asked.

"Not well at all.  I'm not working."  She fidgeted in her chair.  

"Have you lost your job like your sister?"  I asked.

"No, I have been placed on temporary disability.  Too much fatigue and depression.  I don't feel well.  

"What happened?" I said.  "Tell me the story."    

"I've had a rough year since I've seen you.  My eyes have been terrible, and I began to have more and more nasal congestion.  I developed a sinus infection last fall that the doctors couldn't get under control, and then I began wheezing more and more.  Before I saw you, it had been such a rare occurrence that I had forgotten about ever having the problem.  Now I am on inhalers.  Not only that, but my stomach has been acting up, I've had bowel problems and they tell me I now have an "irritable bowel".  As all of this was occurring, I began to get more and more tired, and finally saw a psychiatrist.  I'm on medication, but he agreed that my mental focus and fatigue have been so bad that I can no longer do my job, so he put me on a leave of absence for six months."  With that, she handed me a list of her medications.  

After running through the list of medications she handed me,--and it was now a long list--I mentioned to her that I didn't see her allergy drops listed.

"That's the whole point of wanting to see you again" she said.  "I went off of the allergy drops because my insurance wasn't paying for them, and I want to get back on them."

"This all began when I went off of my drops...."

...I can't begin to tell you the mix of emotions that overwhelmed me at that moment.  It was a combination of anger at the insurance company for their short-sighted efforts at "cost management", my pity for Annie's problems, and my own apparent failure as Annie's physician in emphasizing how important allergy immunotherapy was in maintaining her overall health.  Without SLIT, she had the violent onset of the so-called "allergic march" throughout her system.  Not only were her respiratory tract symptoms spreading, but her bowel problems and even her central nervous system symptoms were in large part from allergy.  In a private practice, we don't have the luxury of doing "clinical trials" with control groups, but there sat her sister, barely 2 feet away, who was stressed from losing her job, and despite her stress was doing excellently while maintaining her immunotherapy.  In my mind, this was as good a "control group" as any.  

As allergists, our use of immunotherapy separates us from our colleagues.  It is our only tool for truly modifying disease. All the drugs in the world can't take the place of one single course of immunotherapy.  

Two sisters.  Two different stories.  One important moral.  

Something to think about.

Later, Dude.



Posted on Saturday, January 22, 2011 at 04:28PM by Registered CommenterGeorge F Kroker MD FACAAI in | CommentsPost a Comment

The Trouble With Physics...AND Allergy

Sometimes, our greatest insights can come in the most unexpected places...I'm reading a very interesting book entitled "The Trouble With Physics" by Dr. Lee Smolin.  His book is a spot-on critique of the modern physics field as it exists today.  Basically, his thesis is that after decades of impressive breakthroughs in the field, physics has come to a virtual grinding halt since the early 1980s, largely because (he posits) there has been an overemphasis on String Theory as the means to make further key breakthroughs in the field.  

He feels the physics community has not encouraged much discussion or investigation into other theories that could bring greater insight into the field.  And hence, the field languishes.  

What does this have to do with our field of Allergy?  Plenty. Our over-emphasis on IgE mediated diseases, and narrowing of our interest into Allergic Rhintis and Asthma nearly exclusively, is our own version of narrowing our view to "String Theory".  

In his first Chapter, he writes an interesting exposition on "The Five Great Problems in Theoretical Physics". As an Allergist and clinician, I have my own list of "Five Great Problems in Allergy".  Unfortunately, I don't think you'll see these "problems" talked about much at our national meetings.  They are truly the "Elephant in the Room" that nobody talks about.

Here's my own list of the Five Great Problems in Allergy:

 1.  The failure of the Allergist to think in terms of "one mucosal membrane" instead of just "one respiratory tract" in holistically looking at the target organs for the allergic patient.  Many asthmatics, for example, come to see me because of irritable bowel symptomatology that their allergist has chosen to  ignore, focusing solely on the respiratory tract.  More often than not, hidden food sensitivities are being missed...

2.   The nature of delayed food sensitivities and the development of a reliable test to diagnose them.  Just yesterday I got (still) another brochure from a lab expounding on their proprietary lab test for delayed food sensitivities.  The investigation into delayed food sensitivities, critiquing the current tests available, etc. has been largely ignored in our profession. Meanwhile, I find increasing numbers of non-allergists using these tests to diagnose delayed-onset food sensitivities.  Where is our research and interest in this area?  Occasionally, there is an oasis in this desert, and one of the articles I've found fascinating is the one by Lied, et al. entitled "Intestinal B Cell-activating Factor:  An Indicator of Non-IgE mediated Hypersensitivity Reactions to Food" published in Alimentary Pharmacology & Therapeutics this year.   The authors correctly point out that "Patients with self-reported food hypersensitivity complain of a wide range of unexplained somatic symptoms related to the intake of food."  In these patients, B cell activating factor levels in serum and gut lavage fluids were significantly higher in these patients than in controls.  Unfortunately, articles like this are "few and far between" and notice that this particular article wasn't published in a "mainstream" allergy journal at all!  Maybe if we ignore delayed-onset food sensitivity, then it will go away, right?  Wrong. 

3.  The lack of understanding and investigation into the nature of delayed sensitivities to mold allergens.  Traditionally, we're told not to be concerned that delayed reactions occur on skin testing to patients because we don't really know what they mean.  But does that mean they aren't important and worth investigating?  I think not.  The fact that some patients have delayed reactions to molds strongly suggests the plausibility of biological significance in the patient.  We ignore it.  At our own detriment--and our patients.

4.  The lack of understanding and investigation into the nature of illness related to Candida Albicans.  I've got an entire lecture on this subject in my "powerpoint lectures and annotated bibliography" section on this blog, so I won't go into this further.  Suffice to say, it made by list of the top 5 problems.

5.  The lack of enthusiasm regarding alternative forms of immunotherapy.  As a professional society, we seem to have a defensive posture on sublingual immunotherapy (SLIT).  I truly believe that the defensive posture is borne largely of fear--fear of change and fear of financial discomfort for the practicing allergist.  And it's hard to be creative and open-minded in an atmosphere of fear.  

None of these 5 great problems will be answered by studying IgE mechanisms further, continuing to principally treat asthma, and giving injection immunotherapy in the conventional manner.  What's the risk of not pursuing these Great Questions?  Simply irrelevance for the profession, and further atrophy in our field.  Patients will go to whomever seeks answers to these questions.  And it may not be the board-certified allergist, but the ENT, chiropracter, family physician, etc. that the patient sees.    

These, then are my Five Great Questions in Allergy  Are these your questions too?  

Something to think about.

Later, Dude

Posted on Sunday, November 21, 2010 at 04:58PM by Registered CommenterGeorge F Kroker MD FACAAI in | CommentsPost a Comment

The Very Best "Research Project"--The Problem Patient...who recovers

Let's start with the obvious:  Every doctor wants to help his or her patients. And one of the best--and accepted--ways we do this is to "keep current and up-to-date" on the medical literature.  We attend meetings, read articles, and discuss the latest medical advances with our colleagues, and even embark on research projects of our own to publish data and learn more.  But even with the best of knowledge and employing the latest treatment techniques, sometimes we have "medical mysteries" that could qualify for an episode of "House" on TV. Euphemistically sometimes called "problem patients", they sometimes can be one of the best "research projects" for the practicing allergist.   In short, there is enormous learning potential we might reap when the following scenario occurs:

The "problem patient" who returns to our office, and--through no help of our own--is feeling better and perhaps even is totally well.  

Most of us have had this experience--a patient we've struggled with, in terms of finding the correct diagnosis and/or the correct treatment. We've run tests, tried medications, and each time to no avail.  We've reached a "dead end", and despite our bleak outlook for them, the patient returns and is better.  We're dumbfounded.  Perhaps even have that "deer caught in the headlights" look on our face when we walk in the room and see the patient is so much better.    

And in my own experience it takes quite an act of humility to take a deep swallow, and ADMIT that we didn't help the patient--something--or someone else--did.  To soothe our bruised egos, it's all to easy to "blow off" or deny the patient is "really, truly, better"--especially if we had no hand in it!  But here's the catch--a patient like this may be an extraordinarily valuable teaching tool for us to learn something new and valuable in helping other patients in our practice.  Again, (and I've said this before) the keys to being a superior allergist don't lay in just technical knowledge, our skill-set needs to include a liberal dose of curiosity and compassion with each patient we see.  In short, we need to ask (and hopefully answer) the question as openly and honestly as possible--how did this patient return to health?  Can I learn anything from this patient's experience that might benefit others?  


Time:  late fall, 1978

Scene:  A hospital ward, Chicago Illinois.

A young doctor is paged to answer the phone for an outside call.  He takes the call.  "Dr. Kroker", the patient says, "just wanted to call you and thank you for trying to help me, but because I wasn't getting the help I needed, I began seeing Dr. Truss in Alabama.  He put me on an antifungal medication and I feel so much better--my allergy to molds and foods have nearly gone away!"

I had known the patient well.  She had been a real "problem patient" for me, and I had struggled with her to no avail.  But I was curious.  So I gave Dr. Truss a call.  He explained to me the important role that Candida Albicans seems to have played in many of his sickest patients, and promised to send me a copy of his article when it was published.  

That one phone call by me began a life-long odyssey into treating patients for Candida-related illness over the next 32 years.  (You can download my lecture in the "Powerpoint lectures and annotated SLIT Bibliography section").  Fueled by curiosity, I was  given "the gift" of a phone call from my "problem patient", and I made contact with an individual (Dr. Orian Truss) who could help me view some of my most difficult and challenging cases in a new light.  


Flashback #2:

Time:  Sometime in the early 1980's.

Scene:  A midwest clinic, in the family practice section.

A family physician observes an odd phenomenon:  many of his difficult patients have gone to La Crosse WI and seen a doctor who placed them on "allergy drops"  (SLIT) and they got better.  He asked the question:

how did these patients return to health?  Can I learn anything from this patient's experience that might benefit others?  

Subsequent to this, he called me, and a mutual friendship developed, with sharing of patients over the years and additional healing for many other people.   

Problem patients?  In the truest sense of the term, I think not.  It may sound trite, but problems are merely solutions that haven't been found.  Sometimes, we have the opportunity--the privilege, if you will-- to learn alot from our most difficult cases when they occasionally return to us and are improved after seeing another health-care practitioner or pursuing another treatment that results in dramatic improvement.  If we swallow our pride and egos, and explore a little bit, they can become our own individual "research projects"  and in a sense sometimes even become our benefactors.

Something to think about.

Later, Dude



Posted on Wednesday, October 20, 2010 at 05:27PM by Registered CommenterGeorge F Kroker MD FACAAI in | CommentsPost a Comment